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Goetz ME, Ford CB, Greiner MA, Clark A, Johnson KG, Kaufman BG, Mantri S, Xian Y, O'Brien RJ, O'Brien EC, Lusk JB. Racial Disparities in Low-Value Care in the Last Year of Life for Medicare Beneficiaries With Neurodegenerative Disease. Neurol Clin Pract 2024; 14:e200273. [PMID: 38524836 PMCID: PMC10955333 DOI: 10.1212/cpj.0000000000200273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 03/26/2024]
Abstract
Background and Objectives There are racial disparities in health care services received by patients with neurodegenerative diseases, but little is known about disparities in the last year of life, specifically in high-value and low-value care utilization. This study evaluated racial disparities in the utilization of high-value and low-value care in the last year of life among Medicare beneficiaries with dementia or Parkinson disease. Methods This was a retrospective, population-based cohort analysis using data from North and South Carolina fee-for-service Medicare claims between 2013 and 2017. We created a decedent cohort of beneficiaries aged 50 years or older at diagnosis with dementia or Parkinson disease. Specific low-value utilization outcomes were selected from the Choosing Wisely initiative, including cancer screening, peripheral artery stenting, and feeding tube placement in the last year of life. Low-value outcomes included hospitalization, emergency department visits, neuroimaging services, and number of days receiving skilled nursing. High-value outcomes included receipt of occupational and physical therapy, hospice care, and medications indicated for dementia and/or Parkinson disease. Results Among 70,650 decedents, 13,753 were Black, 55,765 were White, 93.1% had dementia, and 7.7% had Parkinson disease. Adjusting for age, sex, Medicaid dual enrollment status, rural vs urban location, state (NC and SC), and comorbidities, Black decedents were more likely to receive low-value care including colorectal cancer screening (adjusted hazard ratio [aHR] 1.46 [1.32-1.61]), peripheral artery stenting (aHR 1.72 [1.43-2.08]), and feeding tube placement (aHR 2.96 [2.70-3.24]) and less likely to receive physical therapy (aHR 0.73 [0.64-0.85)], dementia medications (aHR 0.90 [0.86-0.95]), or Parkinson disease medications (aHR 0.88 [0.75-1.02]) within the last year of life. Black decedents were more likely to be hospitalized (aHR 1.28 [1.25-1.32]), more likely to be admitted to skilled nursing (aHR 1.09 [1.05-1.13]), and less likely to be admitted to hospice (aHR 0.82 [0.79-0.85]) than White decedents. Discussion We found racial disparities in care utilization among patients with neurodegenerative disease in the last year of life, such that Black decedents were more likely to receive specific low-value care services and less likely to receive high-value supportive care than White decedents, even after adjusting for health status and socioeconomic factors.
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Affiliation(s)
- Margarethe E Goetz
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Cassie B Ford
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Melissa A Greiner
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Amy Clark
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Kim G Johnson
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Brystana G Kaufman
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Sneha Mantri
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Ying Xian
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Richard J O'Brien
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Emily C O'Brien
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Jay B Lusk
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
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Jones KA, Clark AG, Greiner MA, Sandoe E, Giri A, Hammill BG, Van Houtven CH, Higgins A, Kaufman B. Linking Medicare-Medicaid Claims for Patient-Centered Outcomes Research Among Dual-Eligible Beneficiaries. Med Care 2023; 61:S131-S138. [PMID: 37963032 PMCID: PMC10635344 DOI: 10.1097/mlr.0000000000001895] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Evaluation of Medicare-Medicaid integration models' effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation. OBJECTIVE To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries. RESEARCH DESIGN We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data. PARTICIPANTS North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017. MEASURES We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS). RESULTS Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older. CONCLUSIONS Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.
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Affiliation(s)
- Kelley A. Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham
| | - Amy G. Clark
- Department of Population Health Sciences, Duke University School of Medicine, Durham
| | - Melissa A. Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham
| | - Emma Sandoe
- Department of Population Health Sciences, Duke University School of Medicine, Durham
- North Carolina Department of Health and Human Services, Raleigh
| | - Abhigya Giri
- Duke Margolis Center for Health Policy, Duke University, Durham, NC
| | - Bradley G. Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham
| | - Courtney H. Van Houtven
- Department of Population Health Sciences, Duke University School of Medicine, Durham
- Duke Margolis Center for Health Policy, Duke University, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA
| | - Aparna Higgins
- Duke Margolis Center for Health Policy, Duke University, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA
- Ananya Health Solutions LLC, Dunn Loring, VA Medical Center, Durham, NC
| | - Brystana Kaufman
- Department of Population Health Sciences, Duke University School of Medicine, Durham
- Duke Margolis Center for Health Policy, Duke University, Durham, NC
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA
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Pokorney SD, Zepel L, Greiner MA, Fowler VG, Black-Maier E, Lewis RK, Hegland DD, Granger CB, Epstein LM, Carrillo RG, Wilkoff BL, Hardy C, Piccini JP. Lead Extraction and Mortality Among Patients With Cardiac Implanted Electronic Device Infection. JAMA Cardiol 2023; 8:1165-1173. [PMID: 37851461 PMCID: PMC10585491 DOI: 10.1001/jamacardio.2023.3379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/05/2023] [Indexed: 10/19/2023]
Abstract
Importance Complete hardware removal is a class I recommendation for cardiovascular implantable electronic device (CIED) infection, but practice patterns and outcomes remain unknown. Objective To quantify the number of Medicare patients with CIED infections who underwent implantation from 2006 to 2019 and lead extraction from 2007 to 2019 to analyze the outcomes in these patients in a nationwide clinical practice cohort. Design, Setting, and Participants This cohort study included fee-for-service Medicare Part D beneficiaries from January 1, 2006, to December 31, 2019, who had a de novo CIED implantation and a CIED infection more than 1 year after implantation. Data were analyzed from January 1, 2005, to December 31, 2019. Exposure A CIED infection, defined as (1) endocarditis or infection of a device implant and (2) documented antibiotic therapy. Main Outcomes and Measures The primary outcomes of interest were device infection, device extraction, and all-cause mortality. Time-varying multivariable Cox proportional hazards regression models were used to evaluate the association between extraction and survival. Results Among 1 065 549 patients (median age, 78.0 years [IQR, 72.0-84.0 years]; 50.9% male), mean (SD) follow-up was 4.6 (2.9) years after implantation. There were 11 304 patients (1.1%) with CIED infection (median age, 75.0 years [IQR, 67.0-82.0 years]); 60.1% were male, and 7724 (68.3%) had diabetes. A total of 2102 patients with CIED infection (18.6%) underwent extraction within 30 days of diagnosis. Infection occurred a mean (SD) of 3.7 (2.4) years after implantation, and 1-year survival was 68.3%. There was evidence of highly selective treatment, as most patients did not have extraction within 30 days of diagnosed infection (9202 [81.4%]), while 1511 (13.4%) had extraction within 6 days of diagnosis and 591 (5.2%) had extraction between days 7 and 30. Any extraction was associated with lower mortality compared with no extraction (adjusted hazard ratio [AHR], 0.82; 95% CI, 0.74-0.90; P < .001). Extraction within 6 days was associated with even lower risk of mortality (AHR, 0.69; 95% CI, 0.61-0.78; P < .001). Conclusions and Relevance In this study, a minority of patients with CIED infection underwent extraction. Extraction was associated with a lower risk of death compared with no extraction. The findings suggest a need to improve adherence to guideline-directed care among patients with CIED infection.
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Affiliation(s)
- Sean D. Pokorney
- Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Lindsay Zepel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Melissa A. Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Vance G. Fowler
- Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Christopher B. Granger
- Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Jonathan P. Piccini
- Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Pierce JB, Blumer V, Choi S, Hardy NC, Greiner MA, Carnicelli AP, Shen X, Lippmann SJ, Peterson PN, Allen LA, Fonarow GC, Mentz RJ, Greene SJ, O'Brien EC. Comparative Outcomes of Sacubitril/Valsartan Use After Hospitalization for Heart Failure Among Medicare Beneficiaries Naïve to Renin-Angiotensin System Inhibitors. Am J Cardiol 2023; 204:151-158. [PMID: 37544137 DOI: 10.1016/j.amjcard.2023.07.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/14/2023] [Indexed: 08/08/2023]
Abstract
Sacubitril/valsartan improves outcomes in patients with heart failure with reduced ejection fraction (HFrEF) compared with angiotensin-converting enzyme inhibitors (ACEis). However, data on postdischarge outcomes in renin-angiotensin system inhibitor (RASi)-naïve patients are limited. We included Medicare beneficiaries aged ≥65 years who were hospitalized for HFrEF in the Get With The Guidelines-Heart Failure registry between October 2015 and June 2019, had part D prescription coverage, and were not on RASi therapy during the 6 months before hospital admission. We examined the associations between sacubitril/valsartan prescription at hospital discharge and outcomes at 30 days and 1 year after discharge using overlap-weighted median regression and Cox proportional hazards models. The end points included "home time" (defined as days alive and out of any health care institution), mortality, and rehospitalization. Among 3,572 patients with HFrEF and who are naïve to RASi therapy, at discharge, 290 (8.1%) were prescribed sacubitril/valsartan and 1,390 (38.9%) were prescribed ACEis and angiotensin receptor blockers. After adjusting for baseline characteristics, patients prescribed sacubitril/valsartan had a longer median home time (parameter estimate 27.0 days, 95% confidence interval [CI] 12.40 to 41.6, p <0.001) and lower all-cause mortality (hazard ratio [HR] 0.74, 95% CI 0.61 to 0.91, p = 0.004) at 1 year than patients not prescribed sacubitril/valsartan. The prescription of sacubitril/valsartan was not significantly associated with all-cause rehospitalization (HR 0.87, 95% CI 0.74 to 1.03, p = 0.10) or heart failure rehospitalization (HR 0.87, 95% CI 0.70 to 1.07, p = 0.19). In a restricted comparison of patients discharged on sacubitril/valsartan versus ACEis and angiotensin receptor blockers, there were no significant differences in the outcomes. In conclusion, in this contemporary population of RASi-naïve patients with HFrEF from routine clinical practice, compared with not initiating, the initiation of sacubitril/valsartan at discharge was associated with longer home time and improvements in overall survival.
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Affiliation(s)
- Jacob B Pierce
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | - Sujung Choi
- Duke Department of Population Health Sciences, Durham, North Carolina
| | - N Chantelle Hardy
- Duke Department of Population Health Sciences, Durham, North Carolina
| | - Melissa A Greiner
- Duke Department of Population Health Sciences, Durham, North Carolina
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Xian Shen
- Novartis Pharmaceutical Corporation, East Hanover, New Jersey
| | - Steven J Lippmann
- Duke Department of Population Health Sciences, Durham, North Carolina
| | - Pamela N Peterson
- Denver Health Medical Center, Denver, Colorado; University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
| | - Emily C O'Brien
- Duke Department of Population Health Sciences, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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Lusk JB, Choi S, Clark AG, Johnson K, Ford CB, Greiner MA, Goetz M, Kaufman BG, O'Brien R, O'Brien EC. Dementia and Parkinson's disease diagnoses in electronic health records vs. Medicare claims data: a study of 101,980 linked patients. BMC Neurol 2023; 23:325. [PMID: 37700254 PMCID: PMC10496225 DOI: 10.1186/s12883-023-03361-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/07/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Medicare claims and electronic health record data are both commonly used for research and clinical practice improvement; however, it is not known how concordant diagnoses of neurodegenerative diseases (NDD, comprising dementia and Parkinson's disease) are in these data types. Therefore, our objective was to determine the sensitivity and specificity of neurodegenerative disease (NDD) diagnoses contained in structured electronic health record (EHR) data compared to Medicare claims data. METHODS This was a retrospective cohort study of 101,980 unique patients seen at a large North Carolina health system between 2013-2017, which were linked to 100% North and South Carolina Medicare claims data, to evaluate the accuracy of diagnoses of neurodegenerative diseases in EHRs compared to Medicare claims data. Patients age > 50 who were enrolled in fee-for-service Medicare were included in the study. Patients were classified as having or not having NDD based on the presence of validated ICD-CM-9 or ICD-CM-10 codes associated with NDD or claims for prescription drugs used to treat NDD. EHR diagnoses were compared to Medicare claims diagnoses. RESULTS The specificity of any EHR diagnosis of NDD was 99.0%; sensitivity was 61.3%. Positive predictive value and negative predictive value were 90.8% and 94.1% respectively. Specificity of an EHR diagnosis of dementia was 99.0%, and sensitivity was 56.1%. Specificity of an EHR diagnosis of PD was 99.7%, while sensitivity was 76.1%. CONCLUSIONS More research is needed to investigate under-documentation of NDD in electronic health records relative to Medicare claims data, which has major implications for clinical practice (particularly patient safety) and research using real-world data.
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Affiliation(s)
- Jay B Lusk
- Duke University School of Medicine, DUMC 3710, Durham, NC, 27710, USA.
- Duke University Fuqua School of Business, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Department of Neurology, Duke University, Durham, NC, USA.
| | - Sujung Choi
- Janssen Scientific Affairs, Inc, Titusville, NJ, USA
| | - Amy G Clark
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Kim Johnson
- Department of Neurology, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Brystana G Kaufman
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Emily C O'Brien
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
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Kaufman BG, Jones KA, Greiner MA, Giri A, Stewart L, He A, Clark AG, Taylor DH, Bundorf MK, Whitaker RG, Van Houtven CH, Higgins A. Health Care Use and Spending Among Need-Based Subgroups of Medicare Beneficiaries With Full Medicaid Benefits. JAMA Health Forum 2023; 4:e230973. [PMID: 37171797 PMCID: PMC10182424 DOI: 10.1001/jamahealthforum.2023.0973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Importance Beneficiaries dual eligible for Medicare and Medicaid account for a disproportionate share of expenditures due to their complex care needs. Lack of coordination between payment programs creates misaligned incentives, resulting in higher costs, fragmented care, and poor health outcomes. Objective To inform the design of integrated programs by describing the health care use and spending for need-based subgroups in North Carolina's full benefit, dual-eligible population. Design, Setting, and Participants This cross-sectional study using Medicare and North Carolina Medicaid 100% claims data (2014-2017) linked at the individual level included Medicare beneficiaries with full North Carolina Medicaid benefits. Data were analyzed between 2021 and 2022. Exposure Need-based subgroups: community well, home- and community-based services (HCBS) users, nursing home (NH) residents, and intensive behavioral health (BH) users. Measures Medicare and Medicaid utilization and spending per person-year (PPY). Results The cohort (n = 333 240) comprised subgroups of community well (64.1%, n = 213 667), HCBS users (15.0%, n = 50 095), BH users (15.2%, n = 50 509), and NH residents (7.5%, n = 24 927). Overall, 61.1% reported female sex. The most common racial identities included Asian (1.8%), Black (36.1%), and White (58.7%). Combined spending for Medicare and Medicaid was $26 874 PPY, and the funding of care was split evenly between Medicare and Medicaid. Among need-based subgroups, combined spending was lowest among community well at $19 734 PPY with the lowest portion (38.5%) of spending contributed by Medicaid ($7605). Among NH residents, overall spending ($68 359) was highest, and the highest portion of spending contributed by Medicaid (70.1%). Key components of spending among HCBS users' combined total of $40 069 PPY were clinician services on carrier claims ($14 523) and outpatient facility services ($9012). Conclusions and relevance Federal and state policy makers and administrators are developing strategies to integrate Medicare- and Medicaid-funded health care services to provide better care to the people enrolled in both programs. Substantial use of both Medicare- and Medicaid-funded services was found across all need-based subgroups, and the services contributing a high proportion of the total spending differed across subgroups. The diversity of health care use suggests a tailored approach to integration strategies with comprehensive set benefits that comprises Medicare and Medicaid services, including long-term services and supports, BH, palliative care, and social services.
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Affiliation(s)
- Brystana G Kaufman
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina
| | - Kelley A Jones
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Melissa A Greiner
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Abhigya Giri
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Lucas Stewart
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Amanda He
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Amy G Clark
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Donald H Taylor
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Sanford School of Public Health Policy, Duke University, Durham, North Carolina
| | - M Kate Bundorf
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Sanford School of Public Health Policy, Duke University, Durham, North Carolina
| | - Rebecca G Whitaker
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Courtney H Van Houtven
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina
| | - Aparna Higgins
- Duke Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Founder, Ananya Health Solutions LLC, Dunn Loring, Virginia
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Dzimitrowicz HE, Wilson LE, Jackson BE, Spees LP, Baggett CD, Greiner MA, Kaye DR, Zhang T, George D, Scales CD, Pritchard JE, Leapman MS, Gross CP, Dinan MA, Wheeler SB. End-of-Life Care for Patients With Metastatic Renal Cell Carcinoma in the Era of Oral Anticancer Therapy. JCO Oncol Pract 2023; 19:e213-e227. [PMID: 36413741 PMCID: PMC9970274 DOI: 10.1200/op.22.00401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/31/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE New therapies including oral anticancer agents (OAAs) have improved outcomes for patients with metastatic renal cell carcinoma (mRCC). However, little is known about the quality of end-of-life (EOL) care and systemic therapy use at EOL in patients receiving OAAs or with mRCC. METHODS We retrospectively analyzed EOL care for decedents with mRCC in two parallel cohorts: (1) patients (RCC diagnosed 2004-2015) from the University of North Carolina's Cancer Information and Population Health Resource (CIPHR) and (2) patients (diagnosed 2007-2015) from SEER-Medicare. We assessed hospice use in the last 30 days of life and existing measures of poor-quality EOL care: systemic therapy, hospital admission, intensive care unit admission, and > 1 ED visit in the last 30 days of life; hospice initiation in the last 3 days of life; and in-hospital death. Associations between OAA use, patient and provider characteristics, and EOL care were examined using multivariable logistic regression. RESULTS We identified 410 decedents in the CIPHR cohort (53.4% received OAA) and 1,508 in SEER-Medicare (43.5% received OAA). Prior OAA use was associated with increased systemic therapy in the last 30 days of life in both cohorts (CIPHR: 26.5% v 11.0%; P < .001; SEER-Medicare: 23.4% v 11.7%; P < .001), increased in-hospital death in CIPHR, and increased hospice in the last 30 days in SEER-Medicare. Older patients were less likely to receive systemic therapy or be admitted in the last 30 days or die in hospital. CONCLUSION Patients with mRCC who received OAAs and younger patients experienced more aggressive EOL care, suggesting opportunities to optimize high-quality EOL care in these groups.
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Affiliation(s)
| | - Lauren E. Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Lisa P. Spees
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC
| | - Christopher D. Baggett
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
- Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC
| | - Melissa A. Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Deborah R. Kaye
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Tian Zhang
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Medical Oncology, Department of Medicine, Duke University, Durham, NC
| | - Daniel George
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Charles D. Scales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC
| | - Jessica E. Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Michael S. Leapman
- Department of Urology, Yale School of Medicine, New Haven, CT
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Michaela A. Dinan
- Department of Medicine, Yale School of Medicine, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC
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8
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Pierce JB, Li Z, Greiner MA, Lippmann SJ, Hardy NC, Shen X, Stampehl M, Mentz RJ, Allen LA, Peterson PN, Fonarow GC, O'Brien EC, Greene SJ. Adoption of Sacubitril/Valsartan Among Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction: The Get With The Guidelines-Heart Failure Registry. Circ Heart Fail 2023; 16:e010176. [PMID: 36314141 DOI: 10.1161/circheartfailure.122.010176] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Jacob B Pierce
- Department of Medicine (J.B.P., R.J.M., E.C.O., S.J.G.), Duke University School of Medicine, Durham, NC
| | - Zhen Li
- Department of Population Health Sciences (Z.L., M.A.G., S.J.L., N.C.H.), Duke University School of Medicine, Durham, NC
| | - Melissa A Greiner
- Department of Population Health Sciences (Z.L., M.A.G., S.J.L., N.C.H.), Duke University School of Medicine, Durham, NC
| | - Steven J Lippmann
- Department of Population Health Sciences (Z.L., M.A.G., S.J.L., N.C.H.), Duke University School of Medicine, Durham, NC
| | - N Chantelle Hardy
- Department of Population Health Sciences (Z.L., M.A.G., S.J.L., N.C.H.), Duke University School of Medicine, Durham, NC
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (X.S., M.S.)
| | - Mark Stampehl
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (X.S., M.S.)
| | - Robert J Mentz
- Department of Medicine (J.B.P., R.J.M., E.C.O., S.J.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute, Durham, NC (R.J.M., E.C.O., S.J.G.)
| | - Larry A Allen
- Palliative and Advanced Illness Research, Center and Department of Medicine, Pennsylvania Perelman School of Medicine, Philadelphia (L.A.A.)
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (P.N.P.).,Division of Cardiology, Denver Health Hospital, CO (P.N.P.)
| | - Gregg C Fonarow
- Department of Medicine, University of California Los Angeles (G.C.F.)
| | - Emily C O'Brien
- Department of Medicine (J.B.P., R.J.M., E.C.O., S.J.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute, Durham, NC (R.J.M., E.C.O., S.J.G.)
| | - Stephen J Greene
- Department of Medicine (J.B.P., R.J.M., E.C.O., S.J.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute, Durham, NC (R.J.M., E.C.O., S.J.G.)
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9
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Weissler EH, Osazuwa-Peters OL, Greiner MA, Hardy NC, Kougias P, O’Brien SM, Mark DB, Jones WS, Secemsky EA, Vekstein AM, Shalhub S, Mussa FF, Patel MR, Vemulapalli S. Initial Thoracic Endovascular Aortic Repair vs Medical Therapy for Acute Uncomplicated Type B Aortic Dissection. JAMA Cardiol 2023; 8:44-53. [PMID: 36334259 PMCID: PMC9637274 DOI: 10.1001/jamacardio.2022.4187] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022]
Abstract
Importance Thoracic endovascular aortic repair (TEVAR) has increasingly been used for uncomplicated type B aortic dissection (uTBAD) despite limited supporting data. Objective To assess whether initial TEVAR following uTBAD is associated with reduced mortality or morbidity compared with medical therapy alone. Design, Setting, and Participants This cohort study included Centers for Medicare & Medicaid Services inpatient claims data for adults aged 65 years or older with index admissions for acute uTBAD from January 1, 2011, to December 31, 2018, with follow-up available through December 31, 2019. Exposures Initial TEVAR was defined as TEVAR within 30 days of admission for acute uTBAD. Main Outcomes and Measures Outcomes included all-cause mortality, cardiovascular hospitalizations, aorta-related and repeated aorta-related hospitalizations, and aortic interventions associated with initial TEVAR vs medical therapy. Propensity score inverse probability weighting was used. Results Of 7105 patients with eligible index admissions for acute uTBAD, 1140 (16.0%) underwent initial TEVAR (623 [54.6%] female; median age, 74 years [IQR, 68-80 years]) and 5965 (84.0%) did not undergo TEVAR (3344 [56.1%] female; median age, 76 years [IQR, 69-83 years]). Receipt of TEVAR was associated with region (vs South; Midwest: adjusted odds ratio [aOR], 0.66 [95% CI, 0.53-0.81]; P < .001; Northeast: aOR, 0.63 [95% CI, 0.50-0.79]; P < .001), Medicaid dual eligibility (aOR, 0.76; 95% CI, 0.63-0.91; P = .003), hypertension (aOR, 1.26; 95% CI, 1.03-1.54; P = .03), peripheral vascular disease (aOR, 1.24; 95% CI, 1.02-1.49; P = .03), and year of admission (2012, 2013, 2014, and 2015 were associated with greater odds of TEVAR compared with 2011). After inverse probability weighting, mortality was similar for the 2 strategies up to 5 years (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06), as were aorta-related hospitalizations (HR, 1.12; 95% CI, 0.99-1.27), aortic interventions (HR, 1.01; 95% CI, 0.84-1.20), and cardiovascular hospitalizations (HR, 1.05; 95% CI, 0.93-1.20). In a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality over a period of 1 year (adjusted HR [aHR], 0.86; 95% CI, 0.75-0.99; P = .03), 2 years (aHR, 0.85; 95% CI, 0.75-0.96; P = .008), and 5 years (aHR, 0.87; 95% CI, 0.80-0.96; P = .004). Conclusions and Relevance In this study, 16.0% of patients underwent initial TEVAR within 30 days of uTBAD, and receipt of initial TEVAR was associated with hypertension, peripheral vascular disease, region, Medicaid dual eligibility, and year of admission. Initial TEVAR was not associated with improved mortality or reduced hospitalizations or aortic interventions over a period of 5 years, but in a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality. These findings, along with cost-effectiveness and quality of life, should be assessed in a prospective trial in the US population.
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Affiliation(s)
- E. Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Melissa A. Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - N. Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Panagiotis Kougias
- Division of Vascular and Endovascular Surgery, SUNY Downstate Health Sciences University, Brooklyn, New York
| | | | - Daniel B. Mark
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - W. Schuyler Jones
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Eric A. Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Andrew M. Vekstein
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Sherene Shalhub
- Division of Vascular Surgery, University of Washington, Seattle
| | - Firas F. Mussa
- Section of Vascular Surgery, Imperial College London, London, England
| | - Manesh R. Patel
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke University Medical Center, Durham, North Carolina
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10
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Lusk JB, Ford C, Clark AG, Greiner MA, Johnson K, Goetz M, Kaufman BG, Mantri S, Xian Y, O'Brien R, O'Brien EC. Racial/ethnic disparities in dementia incidence, outcomes, and health‐care utilization. Alzheimers Dement 2022. [DOI: 10.1002/alz.12891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Jay B. Lusk
- Duke University School of Medicine Durham North Carolina USA
- Duke University Fuqua School of Business Durham North Carolina USA
| | - Cassie Ford
- Department of Population Health Sciences Duke University Durham North Carolina USA
| | - Amy G. Clark
- Department of Population Health Sciences Duke University Durham North Carolina USA
| | - Melissa A. Greiner
- Department of Population Health Sciences Duke University Durham North Carolina USA
| | - Kim Johnson
- Department of Neurology Duke University Durham North Carolina USA
- Department of Psychiatry and Behavioral Sciences Duke University Duke University Medical Center Durham North Carolina USA
| | - Margarethe Goetz
- Department of Neurology Duke University Durham North Carolina USA
| | - Brystana G. Kaufman
- Department of Population Health Sciences Duke University Durham North Carolina USA
| | - Sneha Mantri
- Department of Neurology Duke University Durham North Carolina USA
| | - Ying Xian
- Department of Neurology University of Texas‐Southwestern Dallas Texas USA
- Department of Population and Data Sciences University of Texas‐Southwestern Dallas Texas USA
| | - Richard O'Brien
- Department of Neurology Duke University Durham North Carolina USA
| | - Emily C. O'Brien
- Department of Population Health Sciences Duke University Durham North Carolina USA
- Department of Neurology Duke University Durham North Carolina USA
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11
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Copeland JN, Jones K, Maslow GR, French A, Davis N, Greiner MA, Heilbron N, Pullen SJ. Use of North Carolina Medicaid Collaborative Care Billing Codes After Statewide Approval for Reimbursement. Psychiatr Serv 2022; 73:1420-1423. [PMID: 35734864 DOI: 10.1176/appi.ps.202200027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Effective October 2018, North Carolina Medicaid approved reimbursement for collaborative care model (CoCM) billing codes. From October 2018 through December 2019, only 915 of the estimated two million eligible Medicaid beneficiaries had at least one CoCM claim, and the median number of claims per patient was two. Availability of reimbursement for CoCM Medicaid billing codes in North Carolina did not immediately result in robust utilization of CoCM. Furthermore, the low median number of claims per patient suggests lack of fidelity to CoCM. A better understanding of barriers to CoCM implementation is necessary to expand utilization of this evidence-based model.
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Affiliation(s)
- J Nathan Copeland
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Kelley Jones
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Gary R Maslow
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Alexis French
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Naomi Davis
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Melissa A Greiner
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Nicole Heilbron
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
| | - Samuel J Pullen
- Department of Psychiatry and Behavioral Sciences (Copeland, Maslow, French, Davis, Heilbron, Pullen) and Department of Population Health Sciences (Jones, Greiner), Duke University School of Medicine, Durham, North Carolina
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12
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French A, Jones KA, Bush C, Greiner MA, Copeland JN, Davis NO, Franklin MS, Heilbron N, Maslow GR. Racial and Ethnic Differences in Psychotropic Prescription Receipt Among Pediatric Patients Enrolled in North Carolina Medicaid. Psychiatr Serv 2022; 73:1401-1404. [PMID: 36039550 DOI: 10.1176/appi.ps.202100473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors aimed to examine racial-ethnic differences in filled psychotropic prescriptions among a pediatric Medicaid population. METHODS This retrospective cohort study included patients ages 0-21 with at least one North Carolina Medicaid claim from October 1, 2017, through September 30, 2018 (N=983,886). The primary outcome was a filled psychotropic prescription. Separate multivariable modified Poisson regression models generated adjusted risk ratios (ARRs) and 95% confidence intervals (CIs), adjusted for patient demographic characteristics. RESULTS Black and Hispanic patients were significantly less likely to receive any filled psychotropic prescription (ARR=0.61, 95% CI=0.60-0.62; ARR=0.29, 95% CI=0.28-0.29, respectively) compared with White and non-Hispanic patients. Furthermore, Black and Hispanic patients were less likely to receive filled prescriptions in the four included drug classes compared with White and non-Hispanic patients. CONCLUSIONS Future studies should focus on understanding the factors contributing to racial and ethnic differences among pediatric patients receiving filled psychotropic prescriptions.
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Affiliation(s)
- Alexis French
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Kelley A Jones
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Christopher Bush
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Melissa A Greiner
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - J Nathan Copeland
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Naomi O Davis
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Michelle S Franklin
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Nicole Heilbron
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
| | - Gary R Maslow
- Department of Psychiatry and Behavioral Sciences (French, Copeland, Davis, Heilbron, Maslow), Department of Population Health Sciences (Jones, Greiner), and Department of Pediatrics (Maslow), Duke University School of Medicine, Durham, North Carolina; Aetion, New York City (Bush); Duke-Margolis Center for Health Policy, Durham, North Carolina (Franklin); Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill (Franklin)
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13
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Dinan MA, Wilson LE, Greiner MA, Spees LP, Pritchard JE, Zhang T, Kaye D, George D, Scales CD, Baggett CD, Gross CP, Leapman MS, Wheeler SB. Oral Anticancer Agent (OAA) Adherence and Survival in Elderly Patients With Metastatic Renal Cell Carcinoma (mRCC). Urology 2022; 168:129-136. [PMID: 35878815 PMCID: PMC9588695 DOI: 10.1016/j.urology.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/27/2022] [Accepted: 07/10/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine real-world adherence to oral anticancer agents (OAAs) and its association with outcomes among Medicare beneficiaries with metastatic renal cell carcinoma (mRCC). METHODS SEER-Medicare retrospective cohort study of patients with metastatic renal cell carcinoma (mRCC) who received an OAA between 2007 and 2015. We examined A) adherence and B) overall and disease-specific 2-year survival landmarked at 3 months after OAA initiation. Adherence was assessed by calculating the proportion of days covered (PDC) within 3 months of OAA initiation, with adherent use being defined as PDC > 80%. RESULTS A total of 905 patients met study criteria, of whom 445 patients (49.2%) were categorized as adherent to initial OAA treatment. Adjusting for clinical and demographic factors revealed decreased odds of adherence associated with living within an impoverished neighborhood (OR 0.49, CI 0.0.33 - 0.74) and out-of-pocket costs > $200 (OR 0.68, CI 0.47-.98). Adherence was associated with improved 2-year survival in univariate analysis (logrank test, P = .01) and a non-significant trend toward an association with decreased all-cause (HR 0.87, CI 0.72 - 1.05) and RCC-specific survival (HR 0.84, CI 0.69 - 1.03) in multivariable analysis. CONCLUSION Local poverty levels and high out-of-pocket costs are associated with poor initial adherence to OAA therapy in Medicare beneficiaries with mRCC, which in turn, suggests a trend toward poor overall and disease-specific survival. Efforts to improve outcomes in the broader mRCC population should incorporate OAA adherence and economic factors.
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Affiliation(s)
- Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT.
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC; Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Tian Zhang
- Duke Cancer Institute, Durham, NC; Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Deborah Kaye
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC
| | - Daniel George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Department of Surgery (Urology), Duke University School of Medicine, Durham, NC
| | - Chris D Baggett
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC; Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC
| | - Cary P Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT; Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Michael S Leapman
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT; Department of Urology, Yale School of Medicine, New Haven, CT
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC; Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
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14
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Spees LP, Dinan MA, Jackson BE, Baggett CD, Wilson LE, Greiner MA, Kaye DR, Zhang T, George DJ, Scales CD, Pritchard JE, Leapman M, Gross CP, Wheeler SB. Patient- And Provider-Level Predictors of Survival Among Patients With Metastatic Renal Cell Carcinoma Initiating Oral Anticancer Agents. Clin Genitourin Cancer 2022; 20:e396-e405. [PMID: 35595633 PMCID: PMC9529768 DOI: 10.1016/j.clgc.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE In an era of rapid expansion of FDA approvals for oral anticancer agents (OAAs), it is important to understand the factors associated with survival among real-world populations, which include groups not well-represented in pivotal clinical trials of OAAs, such as the elderly, racial minorities, and medically complex patients. Our objective was to evaluate patient- and provider-level characteristics' associations with mortality among a multi-payer cohort of metastatic renal cell carcinoma (mRCC) patients who initiated OAAs. METHODS This retrospective cohort study was conducted using data from the North Carolina state cancer registry linked to multi-payer claims data for the years 2004 to 2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. Included patients were individuals with mRCC who initiated an OAA and survived ≥90 days after beginning treatment. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox hazard models for associations between patient demographics, patient clinical characteristics, provider-level factors, and 2-year all-cause mortality. RESULTS The cohort included 207 patients with mRCC who received OAAs. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, patients solely on Medicare had higher adjusted all-cause mortality compared with patients with any private insurance (HR: 2.35, 95% CL: 1.32-4.18). No provider-level covariates investigated were associated with all-cause mortality. CONCLUSIONS Within a real-world population of mRCC patients taking OAAs, survival differed based on patient characteristics. In an era of rapid expansion of FDA approvals for OAAs, these real-world data underscore the continued importance of access to high-quality care, particularly for medically complex patients with limited resources.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC; Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, NC, USA.
| | - Michaela A Dinan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA; Department of Chronic Disease Epidemiology, Yale School of Medicine, Yale School of Public Health, New Haven, CT, USA
| | - Bradford E Jackson
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, NC, USA
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, NC, USA; Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, NC, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, NC, USA
| | - Deborah R Kaye
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Surgery (Urology), DUSM, Durham, NC, USA
| | - Tian Zhang
- Department of Medicine, DUSM, Durham, NC, USA; Department of Surgery (Urology), DUSM, Durham, NC, USA
| | - Daniel J George
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, NC, USA; Department of Medicine, DUSM, Durham, NC, USA
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, NC, USA; Department of Surgery (Urology), DUSM, Durham, NC, USA
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, NC, USA
| | - Michael Leapman
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA; Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA; Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC; Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, NC, USA; Duke Cancer Institute (DCI), DUSM, Durham, NC, USA
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15
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Franklin MS, Bush C, Jones KA, Davis NO, French A, Howard J, Greiner MA, Maslow GR. Inequities in Receipt of the North Carolina Medicaid Waiver Among Individuals with Intellectual Disability or Autism Spectrum Disorder. J Dev Behav Pediatr 2022; 43:393-401. [PMID: 35353786 PMCID: PMC9462136 DOI: 10.1097/dbp.0000000000001075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 01/07/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We examined characteristics associated with receiving the North Carolina Home and Community-Based Services Waiver for intellectual and developmental disabilities (I/DDs) and its association with emergency department (ED) utilization. METHOD Through analysis of the North Carolina 2017 to 2018 Medicaid claims and enrollment data, we examined characteristics (age, sex, race and ethnicity, geography, diagnosis (intellectual disability [ID] with or without autism spectrum disorders or autism spectrum disorder without ID) associated with receiving the NC I/DD Waiver and the association of this Wavier with ED utilization. We identified patients with at least 1 International Classification of Diseases-10-CM diagnosis code for an ID or autism spectrum disorder. We excluded patients with missing county information and whose enrollment in the NC I/DD Waiver program began after October 1, 2017. RESULTS Only 22% of 53,531 individuals with I/DD in North Carolina received the Waiver. Non-Hispanic Blacks and Hispanic individuals were less likely to receive the Waiver than non-Hispanic White individuals. Adults (>21 years old), men, and urban residents were more likely to receive the Waiver. Individuals who received the Waiver were 31% less likely to use the ED. CONCLUSION Innovative strategies are needed to provide equitable access to the NC I/DD Waiver and provide services to the 14,000 people with I/DD currently waiting to receive the Waiver. Through the Waiver, those with I/DD can access preventative and therapeutic outpatient services and decrease their need for ED care. These findings highlight the need for policy reform to address inequities in access to the Waiver for individuals with I/DD.
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Affiliation(s)
| | - Christopher Bush
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Kelley A. Jones
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Naomi Ornstein Davis
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Alexis French
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Jill Howard
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | | | - Gary R. Maslow
- Department of Pediatrics, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
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Pohlman FW, Ford CB, Weissler EH, Smerek MM, Hardy NC, Narcisse DI, Lippmann SJ, Greiner MA, Long C, Rymer JA, Gutierez JA, Patel MR, Jones WS. Impact of risk factor control on peripheral artery disease outcomes and health disparities. Vasc Med 2022; 27:323-332. [PMID: 35387516 PMCID: PMC10908093 DOI: 10.1177/1358863x221084360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Peripheral artery disease (PAD) is associated with modifiable atherosclerotic risk factors like hypertension, diabetes, hyperlipidemia, and smoking. However, the effect of risk factor control on outcomes and disparities in achieving control is less well understood. METHODS All patients in an integrated, regional health system with PAD-related encounters, fee-for-service Medicare, and clinical risk factor control data were identified. Component risk factors were dichotomized into controlled and uncontrolled categories (control defined as low-density lipoprotein < 100 mg/dL, hemoglobin A1c < 7.0%, SBP < 140 mmHg, and current nonsmoker) and composite categories (none, 1, ⩾ 2 uncontrolled RFs) created. The primary outcome was major adverse vascular events (MAVE, a composite of all-cause mortality, myocardial infarction, stroke, and lower-extremity revascularization and amputation). RESULTS The cohort included 781 patients with PAD, average age 72.5 ± 9.8 years, of whom 30.1% were Black, and 19.1% were Medicaid dual-enrolled. In this cohort, 260 (33.3%) had no uncontrolled risk factors and 200 (25.6%) had two or more uncontrolled risk factors. Patients with the poorest risk factor control were more likely to be Black (p < 0.001), Medicaid dual-enrolled (p < 0.001), and have chronic limb-threatening ischemia (p = 0.009). Significant differences in MAVE by degree of risk factor control were observed at 30 days (none uncontrolled: 5.8%, 1 uncontrolled: 11.5%, ⩾ 2 uncontrolled: 13.6%; p = 0.01) but not at 1 year (p = 0.08). risk factor control was not associated with outcomes at 1 year after adjustment for patient and PAD-specific characteristics. CONCLUSIONS risk factor control is poor among patients with PAD. Significant disparities in achieving optimal risk factor control represent a potential target for reducing inequities in outcomes.
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Affiliation(s)
| | - Cassie B. Ford
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - E. Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC
| | - Michelle M. Smerek
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - N. Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Steven J. Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Melissa A. Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC
| | - Jennifer A. Rymer
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | | | - Manesh R. Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - W. Schuyler Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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17
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Pritchard JE, Wilson LE, Miller SM, Greiner MA, Cohen HJ, Kaye DR, Zhang T, Dinan MA. Association between cognitive impairment and oral anticancer agent use in older patients with metastatic renal cell carcinoma. J Am Geriatr Soc 2022; 70:2330-2343. [PMID: 35499667 PMCID: PMC9378524 DOI: 10.1111/jgs.17826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Kidney cancer is the fastest-growing cancer diagnosis in the developed world. About 16% of new cases are stage IV, which has a low five-year survival rate. Many patients with metastatic renal cell carcinoma (mRCC) are older and may have mild cognitive impairment or dementia (MCI/D). Given prior reports of patients with dementia initiating less cancer therapy and the importance of oral anticancer agents (OAAs) in mRCC treatment, we investigated the prevalence of preexisting MCI/D in patients with mRCC and their OAA use. METHODS SEER-Medicare patients were analyzed who were ≥65 years, diagnosed with mRCC between 2007 and 2015, and had Medicare part D coverage. Patterns and predictors of (a) OAA utilization within the 12 months following mRCC diagnosis and (b) adherence (percent of days covered [PDC] ≥ 80%) during the first 90 days following treatment initiation were assessed. RESULTS Of the 2792 eligible patients, 268 had preexisting MCI/D, and 907 initiated OAA treatment within 12 months of mRCC diagnosis. Patients with preexisting MCI/D were less likely to begin an OAA than those without MCI/D (fully-adjusted HR 0.53, 95% CI 0.38-0.76). Among OAA initiators, a preexisting MCI/D diagnosis did not alter the likelihood that a person would be adherent (adjusted RR 0.84, 95% CI 0.55-1.28). CONCLUSIONS Patients with preexisting MCI/D were half as likely to start an OAA during the year following mRCC diagnosis than patients without comorbid MCI/D. The 90-day adherence of OAA initiators was not significantly different between those with and without preexisting MCI/D. In light of this, clinicians should assess mRCC patients for cognitive impairment and take steps to optimize OAA utilization by those with MCI/D.
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Affiliation(s)
| | | | - Samuel M. Miller
- National Clinician Scholars Program, Yale University
- Department of Surgery, Yale University
| | | | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University
| | | | - Tian Zhang
- Division of Medical Oncology, Department of Medicine, Duke University
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center
| | - Michaela A. Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center
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18
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Miller SM, Wilson LE, Greiner MA, Pritchard JE, Zhang T, Kaye DR, Cohen HJ, Becher RD, Maerz LL, Dinan MA. Evaluation of mild cognitive impairment and dementia in patients with metastatic renal cell carcinoma. J Geriatr Oncol 2022; 13:635-643. [PMID: 34996724 PMCID: PMC9232862 DOI: 10.1016/j.jgo.2021.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Dementia and cancer are both more common in adults as they age. As new cancer treatments become more popular, it is important to consider how these treatments might affect older patients. This study evaluates metastatic renal cell carcinoma (mRCC) as a risk factor for older adults developing mild cognitive impairment or dementia (MCI/D) and the impact of mRCC-directed therapies on the development of MCI/D. METHODS We identified patients diagnosed with mRCC in a Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset from 2007 to 2015 and matched them to non-cancer controls. Exclusion criteria included age < 65 years at mRCC diagnosis and diagnosis of MCI/D within the year preceding mRCC diagnosis. The main outcome was time to incident MCI/D within one year of mRCC diagnosis for cases or cohort entry for non-cancer controls. Cox proportional hazards models were used to measure associations between mRCC and incident MCI/D as well as associations of oral anticancer agent (OAA) use with MCI/D development within the mRCC group. RESULTS Patients with mRCC (n = 2533) were matched to non-cancer controls (n = 7027). mRCC (hazard ratio [HR] 8.52, p < .001), being older (HR 1.05 per 1-year age increase, p < .001), and identifying as Black (HR 1.92, p = .047) were predictive of developing MCI/D. In addition, neither those initiating treatment with OAAs nor those who underwent nephrectomy were more likely to develop MCI/D. CONCLUSIONS Patients with mRCC were more likely to develop MCI/D than those without mRCC. The medical and surgical therapies evaluated were not associated with increased incidence of MCI/D. The increased incidence of MCI/D in older adults with mRCC may be the result of the pathology itself or risk factors common to the two disease processes.
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Affiliation(s)
- Samuel M Miller
- National Clinician Scholars Program, Yale University, USA; Department of Surgery, Yale University, USA.
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University, USA
| | | | | | - Tian Zhang
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, USA
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University, USA
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19
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Kaye DR, Wilson LE, Greiner MA, Spees LP, Pritchard JE, Zhang T, Pollack CE, George D, Scales CD, Baggett CD, Gross CP, Leapman MS, Wheeler SB, Dinan MA. Patient, provider, and hospital factors associated with oral anti-neoplastic agent initiation and adherence in older patients with metastatic renal cell carcinoma. J Geriatr Oncol 2022; 13:614-623. [PMID: 35125336 PMCID: PMC9232903 DOI: 10.1016/j.jgo.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/16/2021] [Accepted: 01/13/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Oral anti-neoplastic agents (OAAs) for metastatic renal cell carcinoma (mRCC) are associated with increased cancer-specific survival. However, racial disparities in survival persist and older adults have the lowest rates of cancer-specific survival. Research from other cancers demonstrates specialty access is associated with high-quality cancer care, but older adults receive cancer treatment less often than younger adults. We therefore examined whether patient, provider, and hospital characteristics were associated with OAA initiation, adherence, and cancer-specific survival after initiation and whether race, ethnicity, and/or age was associated with an increased likelihood of seeing a medical oncologist for diagnosis of mRCC. PATIENTS AND METHODS We used Surveillance, Epidemiology, and End Results (SEER)Medicare data to identify patients ≥65 years of age who were diagnosed with mRCC from 2007 to 2015 and enrolled in Medicare Part D. Insurance claims were used to identify receipt of OAAs within twelve months of metastatic diagnosis, calculate proportion of days covered, and to identify the primary cancer provider and hospital. We examined provider and hospital characteristics associated with OAA initiation, adherence, and all-cause mortality after OAA initiation. RESULTS We identified 2792 patients who met inclusion criteria. Increased OAA initiation was associated with access to a medical oncologist. Patients were less likely to begin OAA treatment if their primary oncologic provider was a urologist (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.49-0.77). Provider/hospital characteristics were not associated with differences in OAA adherence or mortality. Patients who started sorafenib (odds ratio [OR] 0.50; 95% CI 0.29-0.86), were older (aged >81 OR 0.56; 95% CI 0.34-0.92), and those living in high poverty ZIP codes (OR 0.48; 95% CI 0.29-0.80) were less likely to adhere to OAA treatment. Furthermore, provider characteristics did not account for differences in mortality once an OAA was initiated. Last, only age > 81 years was statistically and clinically associated with a decreased relative risk of seeing a medical oncologist (risk ratio [RR] 0.87; CI 0.82-0.92). CONCLUSION Provider/hospital factors, specifically, being seen by a medical oncologist for mRCC diagnosis, are associated with OAA initiation. Older patients were less likely to see a medical oncologist; however, race and/or ethnicity was not associated with differences in seeing a medical oncologist. Patient factors are more critical to OAA adherence and mortality after OAA initiation than provider/hospital factors.
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Affiliation(s)
- Deborah R Kaye
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC, United States of America; Duke-Margolis Policy Center, Duke University School of Medicine, Durham, NC, United States of America; Duke Cancer Institute, Durham, NC, United States of America
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC, United States of America
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Tian Zhang
- Duke Cancer Institute, Durham, NC, United States of America; Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Craig E Pollack
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Daniel George
- Duke Cancer Institute, Durham, NC, United States of America; Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Charles D Scales
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC, United States of America; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Chris D Baggett
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC, United States of America; Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC, United States of America
| | - Cary P Gross
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT, United States of America
| | - Michael S Leapman
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT, United States of America; Department of Urology, Yale School of Medicine, New Haven, CT, United States of America
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC, United States of America
| | - Michaela A Dinan
- Department of Urology, Yale School of Medicine, New Haven, CT, United States of America.
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Malcolm EJ, Brandon Z, Wilson LE, Shoup JP, King HA, Lewinski A, Greiner MA, Malone S, Miller J, Keenan RT, Tarrant TK, Phinney D, Cho A, Bosworth HB, Shah K. eConsults' Impact on Care Access and Wait Times in Rheumatology. J Clin Rheumatol 2022; 28:147-154. [PMID: 35067514 DOI: 10.1097/rhu.0000000000001825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits. METHODS In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program. RESULTS Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition. CONCLUSIONS Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Julie Miller
- From the Duke University School of Medicine, Durham
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Dzimitrowicz HE, Wilson LE, Jackson BE, Spees L, Baggett C, Greiner MA, Kaye D, Zhang T, George DJ, Scales CD, Pritchard J, Leapman MS, Gross CP, Dinan MA, Wheeler SB. Factors associated with the quality of end-of-life care for patients with metastatic renal cell carcinoma. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
300 Background: Although oral anti-cancer agents (OAAs) have improved outcomes for patients with metastatic renal cell carcinoma (mRCC), most patients still die from the disease. High quality end-of-life (EOL) care remains a crucial component of optimal care for patients with mRCC, but neither it nor systemic therapy use at EOL have been well characterized in these patients. Methods: We conducted a retrospective study of decedents with mRCC in 2 cohorts analyzed in parallel: 1) patients aged ≥18 years (diagnosed with RCC in 2004 through 2015) drawn from the University of North Carolina Cancer Information Population Health Resource (NC-CIPHR) and 2) patients aged ≥66 years (diagnosed with RCC in 2007 through 2015) from SEER-Medicare. OAA use was measured from date of mRCC diagnosis until 30 days prior to death. We assessed use of hospice in the last 30 days of life as well as established measures of low EOL care quality: receipt of systemic therapy, hospital admission, and ICU admission in last 30 days of life, and death in hospital. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence limits (95%CL) for associations between OAA use, patient and provider characteristics, and EOL care quality in both cohorts. Results: We identified 410 (NC-CIPHR) and 1508 (SEER-Medicare) patients with median ages of 69 and 75 years, respectively. 53.4% and 43.5% of decedents received an OAA in NC-CIPHR and SEER-Medicare, respectively. OAA use was associated with increased systemic therapy in the last 30 days prior to death in both datasets, increased hospice in the last 30 days prior to death in SEER-Medicare, and increased death in hospital in NC-CIPHR. OAA use was not associated with inpatient or ICU admission near EOL in both cohorts. Older patients were less likely to receive chemotherapy, be admitted, or die in the hospital near EOL in both cohorts. Dual-enrolled beneficiaries (Medicare and Medicaid) had decreased likelihood of hospice use in 30 days prior to death (OR = 0.71; 95%CL: 0.54, 0.94) and increased death in hospital (OR = 1.40; 95%CL: 1.02, 1.93) in SEER-Medicare. Conclusions: Patients with mRCC who received OAAs were more likely to receive systemic therapy at the EOL, however, they were also more likely to receive hospice care at EOL in the SEER-Medicare cohort with no differences in hospitalization near EOL. Future directions include characterization of EOL care in the era of immunotherapy treatments. [Table: see text]
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Affiliation(s)
| | | | | | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Tian Zhang
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
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22
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Steinberg BA, Li Z, Shrader P, Chew DS, Bunch TJ, Mark DB, Nabutovsky Y, Shah RU, Greiner MA, Piccini JP. Bimodal distribution of atrial fibrillation burden in 3 distinct cohorts: What is 'paroxysmal' atrial fibrillation? Am Heart J 2022; 244:149-156. [PMID: 34838507 PMCID: PMC8727503 DOI: 10.1016/j.ahj.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Burden of atrial fibrillation (AF), as a continuous measure, is an emerging alternative classification often assumed to increase linearly with progression of disease. Yet there are no descriptions of AF burden distributions across populations. METHODS We examined patterns of AF burden (% time in AF) across 3 different cohorts: outpatients with AF undergoing Holter monitoring in a national registry (ORBIT-AF II), routine outpatients undergoing Holter monitoring in a tertiary healthcare system (UHealth), and patients >= 65 years with cardiac implantable electronic devices (Merlin.netTM linked to Medicare). RESULTS We included 2,058 ORBIT-AF II patients, 4,537 UHealth patients, and 39,710 from Merlin.net. Mean age ranged from 56 to 77 years, sex ranged from 40% to 61% male, and mean CHA2DS2-VASc scores ranged from 2.2 to 4.9. Across all cohorts, AF burden demonstrated skewed frequency towards the extremes, with the vast majority of patients having either very low or very high AF burden. This bimodal distribution was consistent across cohorts, across clinically-documented AF types (paroxysmal v persistent), patients with or without a known AF diagnosis, and among patients with different types of cardiac implantable electronic devices. CONCLUSIONS Across 3 broad, diverse cohorts with continuous monitoring, distribution of AF burden was consistently skewed towards the extremes without an even, linear distribution or progression. As AF burden is increasingly recognized as a descriptor and potential risk-stratifier, these findings have important implications for future research and patient care.
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Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT.
| | - Zhen Li
- Department of Population Health, Duke University, Durham, NC
| | - Peter Shrader
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Derek S Chew
- Department of Population Health, Duke University, Durham, NC; Duke Clinical Research Institute, Duke University, Durham, NC
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC; Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | | | - Jonathan P Piccini
- Department of Population Health, Duke University, Durham, NC; Duke Clinical Research Institute, Duke University, Durham, NC; Division of Cardiology, Duke University Medical Center, Durham, NC
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Chew DS, Li Z, Steinberg BA, O'Brien E, Pritchard J, Bunch TJ, Mark DB, Patel MR, Nabutovsky Y, Greiner MA, Piccini JP. Association between economic and arrhythmic burden of paroxysmal atrial fibrillation in patients with cardiac implanted electronic devices. Am Heart J 2022; 244:116-124. [PMID: 34800369 DOI: 10.1016/j.ahj.2021.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/08/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND As the prevalence of atrial fibrillation (AF) increases, a greater understanding of the costs associated with AF care is required. While individuals with greater arrhythmic burden may interact with the health system more frequently, the relationship between AF burden and costs remains undefined. METHODS In a longitudinal patient cohort with paroxysmal AF and newly implanted cardiovascular implantable electronic devices (CIED) (2010-2016), we linked CIED remote-monitoring data with Medicare claims to assess the association between the 30-day averaged device-detected daily percentage of time in AF ("AF burden") and healthcare costs. RESULTS Among 39,345 patients, the mean age was 77.1 ± 8.7 years, 60.7% were male, and the mean CHA2DS2-VASc score was 4.9 ± 1.3. The mean total 1-year costs were $18,668 ± 29,173, driven by hospitalization costs where two-thirds of admissions were due to heart failure. Increasing AF burden was associated with increasing costs: $17,860 ± 28,525 for 0% daily AF burden; $18,840 ± 29,104 for 0-5% daily AF burden; and $20,968 ± 31,228 for 5-98% daily AF burden. There was a linear relationship between AF burden expressed as a continuous variable and 1-year costs (adjusted cost rate ratio 1.031 per 10% daily duration in AF, 95% confidence interval 1.023-1.038; P < .001). CONCLUSIONS Among older patients with paroxysmal AF and CIEDs, increasing AF burden is associated with higher healthcare costs. As the observational study design is unable to determine causal relationships, prospective study is required to explore the intriguing hypothesis that targeted AF strategies, including comorbidity management, that reduce AF burden may also reduce the high annual costs associated with AF.
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Weissler EH, Ford CB, Narcisse DI, Lippmann SJ, Smerek MM, Greiner MA, Hardy NC, O'Brien B, Sullivan RC, Brock AJ, Long C, Curtis LH, Patel MR, Jones WS. Clinician Specialty, Access to Care, and Outcomes Among Patients with Peripheral Artery Disease. Am J Med 2022; 135:219-227. [PMID: 34627781 PMCID: PMC8840959 DOI: 10.1016/j.amjmed.2021.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/18/2021] [Accepted: 08/23/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Understanding the relationship between patterns of peripheral artery disease and outcomes is an essential step toward improving care and outcomes. We hypothesized that clinician specialty would be associated with occurrence of major adverse vascular events (MAVE). METHODS Patients with at least 1 peripheral artery disease-related encounter in our health system and fee-for-service Medicare were divided into groups based on the specialty of the clinician (ie, cardiologist, surgeon, podiatrist, primary care, or other) providing a plurality of peripheral artery disease-coded care in the year prior to index encounter. The primary outcome was MAVE (a composite of all-cause mortality, myocardial infarction, stroke, lower extremity revascularization, and lower extremity amputation). RESULTS The cohort included 1768 patients, of whom 30.0% were Black, 23.9% were Medicaid dual-enrollment eligible, and 31.1% lived in rural areas. Patients receiving a plurality of their care from podiatrists had the highest 1-year rates of MAVE (34.4%, P <.001), hospitalization (65.9%, P <.001), and amputations (22.6%, P <.001). Clinician specialty was not associated with outcomes after adjustment. Patients who were Medicaid dual-eligible had higher adjusted risks of mortality (adjusted hazard ratio [HRadj] 1.54, 95% confidence interval [CI] 1.11-2.14) and all-cause hospitalization (HRadj 1.20, 95% CI 1.03-1.40) and patients who were Black had a higher adjusted risk of amputation (HRadj 1.49, 95% CI 1.03-2.15). CONCLUSIONS Clinician specialty was not associated with worse outcomes after adjustment, but certain socioeconomic factors were. The effects of clinician specialty and socioeconomic status were likely attenuated by the fact that all patients in this study had health insurance; these analyses require confirmation in a more representative cohort.
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Affiliation(s)
- E Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC.
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Dennis I Narcisse
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Michelle M Smerek
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Benjamin O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - R Casey Sullivan
- Division of Cardiology, Washington University School of Medicine, St. Louis, Mo
| | - Adam J Brock
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC
| | - Lesley H Curtis
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Clinical Research Institute, Durham, NC
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Clinical Research Institute, Durham, NC
| | - W Schuyler Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC; Clinical Research Institute, Durham, NC
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Chew DS, Li Z, Steinberg BA, O'Brien EC, Pritchard J, Bunch TJ, Mark DB, Patel MR, Nabutovsky Y, Greiner MA, Piccini JP. Arrhythmic Burden and the Risk of Cardiovascular Outcomes in Patients With Paroxysmal Atrial Fibrillation and Cardiac Implanted Electronic Devices. Circ Arrhythm Electrophysiol 2022; 15:e010304. [PMID: 35089799 DOI: 10.1161/circep.121.010304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Whether the amount of atrial fibrillation (AF) patients experience conveys important prognostic information beyond that provided by the diagnosis of AF is uncertain. The study objective was to assess the dose-response relationship between device-detected AF burden and subsequent cardiovascular outcomes. METHODS Among patients with paroxysmal AF who underwent cardiac implantable electronic device implantation (2010-2016), Merlin.net remote-monitoring data were linked to Medicare claims to assess the magnitude and strength of the associations between device-based AF burden (defined as a daily percentage of time spent in AF or maximal AF episode duration ascertained at baseline over 30 days) and key cardiovascular outcomes. RESULTS Among 39 710 patients (mean age 77.1±8.7 years, 60.7% male, and a mean CHA2DS2-VASc score 4.9±1.3), all-cause mortality at 1-year increased with baseline AF burden: 8.54% with AF burden 0%, 8.9% with AF burden 0% to 5%, and 10.9% with AF burden 5% to 98% (P<0.001) There was also a dose-response relationship between increasing AF burden and all-cause or cardiovascular hospitalization and ischemic stroke. Updating AF burden data every 30 days did not alter the AF burden-prognostic relationships determined from the use of baseline data alone. Results were also consistent when 3-year outcomes were considered and after accounting for the use of oral anticoagulants. CONCLUSIONS In paroxysmal AF, there is a clinically relevant dose-response relationship between increasing AF burden and rates of adverse outcomes at 1- and 3-years, including increasing risks of cardiovascular hospitalization, ischemic stroke, and mortality.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute (D.S.C., E.C.O., D.B.M., M.R.P., J.P.P.), Duke University, Durham, NC.,Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, AB, Canada (D.S.C.)
| | - Zhen Li
- Department of Population Health Sciences (Z.L., E.C.O., J.P., M.R.P., M.A.G., J.P.P.), Duke University, Durham, NC
| | - Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City (B.A.S., T.J.B.)
| | - Emily C O'Brien
- Duke Clinical Research Institute (D.S.C., E.C.O., D.B.M., M.R.P., J.P.P.), Duke University, Durham, NC.,Department of Population Health Sciences (Z.L., E.C.O., J.P., M.R.P., M.A.G., J.P.P.), Duke University, Durham, NC
| | - Jessica Pritchard
- Department of Population Health Sciences (Z.L., E.C.O., J.P., M.R.P., M.A.G., J.P.P.), Duke University, Durham, NC
| | - T Jared Bunch
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City (B.A.S., T.J.B.)
| | - Daniel B Mark
- Duke Clinical Research Institute (D.S.C., E.C.O., D.B.M., M.R.P., J.P.P.), Duke University, Durham, NC.,Division of Cardiology (D.B.M., J.P.P.), Duke University, Durham, NC
| | - Manesh R Patel
- Duke Clinical Research Institute (D.S.C., E.C.O., D.B.M., M.R.P., J.P.P.), Duke University, Durham, NC.,Department of Population Health Sciences (Z.L., E.C.O., J.P., M.R.P., M.A.G., J.P.P.), Duke University, Durham, NC
| | | | - Melissa A Greiner
- Department of Population Health Sciences (Z.L., E.C.O., J.P., M.R.P., M.A.G., J.P.P.), Duke University, Durham, NC
| | - Jonathan P Piccini
- Duke Clinical Research Institute (D.S.C., E.C.O., D.B.M., M.R.P., J.P.P.), Duke University, Durham, NC.,Department of Population Health Sciences (Z.L., E.C.O., J.P., M.R.P., M.A.G., J.P.P.), Duke University, Durham, NC.,Division of Cardiology (D.B.M., J.P.P.), Duke University, Durham, NC
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Wilson LE, Spees L, Pritchard J, Greiner MA, Scales CD, Baggett CD, Kaye D, George DJ, Zhang T, Wheeler SB, Dinan MA. Real-World Utilization of Oral Anticancer Agents and Related Costs in Older Adults with Metastatic Renal Cell Carcinoma in the United States. Kidney Cancer 2021; 5:115-127. [PMID: 34632169 PMCID: PMC8474520 DOI: 10.3233/kca-210119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/21/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Substantial racial and socioeconomic disparities in metastatic RCC (mRCC) have persisted following the introduction of targeted oral anticancer agents (OAAs). The relationship between patient characteristics and OAA access and costs that may underlie persistent disparities in mRCC outcomes have not been examined in a nationally representative patient population. METHODS Retrospective SEER-Medicare analysis of patients diagnosed with mRCC between 2007-2015 over age 65 with Medicare part D prescription drug coverage. Associations between patient characteristics, OAA receipt, and associated costs were analyzed in the 12 months following mRCC diagnosis and adjusted to 2015 dollars. RESULTS 2,792 patients met inclusion criteria, of which 32.4%received an OAA. Most patients received sunitinib (57%) or pazopanib (28%) as their first oral therapy. Receipt of OAA did not differ by race/ethnicity or socioeconomic indicators. Patients of advanced age (> 80 years), unmarried patients, and patients residing in the Southern US were less likely to receive OAAs. The mean inflation-adjusted 30-day cost to Medicare of a patient's first OAA prescription nearly doubled from $3864 in 2007 to $7482 in 2015, while patient out-of-pocket cost decreased from $2409 to $1477. CONCLUSION Race, ethnicity, and socioeconomic status were not associated with decreased OAA receipt in patients with mRCC; however, residing in the Southern United States was, as was marital status. Surprisingly, the cost to Medicare of an initial OAA prescription nearly doubled from 2007 to 2015, while patient out-of-pocket costs decreased substantially. Shifts in OAA costs may have significant economic implications in the era of personalized medicine.
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Affiliation(s)
- Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Lisa Spees
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Jessica Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Surgery (Urology), Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA.,Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Deborah Kaye
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC, USA.,Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Duke-Margolis Center for Health Policy, Durham, NC, USA
| | - Daniel J George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Tian Zhang
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Michaela A Dinan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Epidemiology, Yale University, New Haven, CT, USA
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Spees L, Wheeler SB, Jackson BE, Baggett C, Wilson LE, Greiner MA, Kaye D, Zhang T, George DJ, Scales CD, Pritchard J, Leapman MS, Gross CP, Dinan MA. Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
87 Background: While several patient-level factors have been associated with oral anti-cancer agent (OAA) initiation and adherence for metastatic renal cell carcinoma (mRCC) and other cancers, few provider-level factors have been examined, despite providers being a key component driving OAA access. We examined provider and patient characteristics associated with OAA initiation and adherence among individuals with mRCC. Methods: We used linked North Carolina state cancer registry data and multi-payer claims data to identify mRCC patients diagnosed in 2004-2015. A patient’s modal provider was the provider most frequently on claims with a diagnosis code of RCC or metastatic cancer between 2 months prior to and 3 months following the index date. Provider-level variables included specialty, sex, race/ethnicity, years in practice, provider’s RCC patient volume, and practice location. Patient-level control variables of interest included: age at metastatic diagnosis, sex, race/ethnicity, rural location, insurance coverage at metastatic index date, histology, stage at initial diagnosis, radical/partial nephrectomy in the prior year, number of comorbidities at baseline, and frailty. OAA initiation within the 12 months following the patient’s metastatic index date was identified from prescription drug files and pharmacy claims. Adherence to OAAs was defined as having ≥80% proportion of days covered (PDC) for the 90 consecutive days following an initial OAA claim that patients had access to any OAA days’ supply. We estimated risk ratios (RR) and corresponding 95% confidence limits (CL) using modified Poisson regression to evaluate patient- and provider-level factors associated with OAA initiation and adherence. Results: Of the 687 patients in our sample, 37% initiated an OAA following mRCC diagnosis. Patients with a modal provider specializing in hematology/medical oncology were more likely to initiate OAAs than those seen by other specialties (i.e., urology/urological surgery, internal medicine, and other). Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing in urban areas only more likely to initiate OAAs (RR = 1.37; 95%CL:1.09,1.73). Patients who were older, with more comorbid conditions, stage I at initial diagnosis, and greater frailty were less likely to initiate OAAs. Among the 207 patients who initiated an OAA and survived the following 90 days, the median PDC was 0.91. No provider-level factors were associated with OAA adherence. However, Medicare-insured patients were less likely to be adherent (RR = 0.61; 95%CL:0.42,0.87) than those with private insurance. Conclusions: Our results suggest that provider- and patient-level factors are associated with OAA initiation but only patient-level factors are associated with adherence.
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Affiliation(s)
- Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | | | - Deborah Kaye
- Dow Division for Urological Health Services Research, Department of Urology, Ann Arbor, MI
| | - Tian Zhang
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | - Daniel J. George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
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Spees L, Dinan MA, Jackson BE, Baggett C, Wilson LE, Greiner MA, Kaye D, Zhang T, George DJ, Scales CD, Pritchard J, Leapman MS, Gross CP, Wheeler SB. Patient- and provider-level predictors of mortality among patients with metastatic renal cell carcinoma receiving oral anticancer agents. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
116 Background: It is important to understand how emerging new therapies, such as oral anti-cancer agents (OAAs), diffuse across and can improve outcomes within real-world populations, which include age groups and racial groups not well-represented in clinical trials, such as people older than age 65 and Black patients. Our objectives were to examine whether disparities in mortality persist among patients with metastatic renal cell carcinoma (mRCC) receiving OAAs and whether these disparities may be partially explained by patient’s clinical characteristics or provider-level factors. Methods: We used linked state cancer registry data and multi-payer claims data to identify patients with mRCC who were diagnosed in 2004 through 2015 and had initiated an OAA and survived ≥ 90 days after initiating. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. A patient’s modal provider was the provider most frequently on claims with a diagnosis code of RCC or metastatic cancer between 2 months prior to and 3 months following the index date. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox proportional hazard models to evaluate which patient demographics, patient clinical characteristics, and provider-level factors were associated with 2-year all-cause mortality. Results: The cohort included 207 patients with mRCC. In unadjusted analyses, public insurance (Medicaid or Medicare), de novo metastatic diagnosis, frailty, polypharmacy, and a visit to a skilled nursing facility were associated with increased all-cause mortality. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, Medicare-insured patients continued to have higher all-cause mortality compared to privately insured patients (HR: 2.35, 95% CL: 1.32-4.18). None of the provider-level covariates (i.e., specialization, experience, volume, or practice location) investigated were associated with all-cause mortality. Conclusions: Even when adjusting for age, frailty, and comorbidities, Medicare-insured patient had lower overall survival than privately-insured patients. Patient survival did not differ based on modal provider’s characteristics.
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Affiliation(s)
- Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | | | - Deborah Kaye
- Dow Division for Urological Health Services Research, Department of Urology, Ann Arbor, MI
| | - Tian Zhang
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | - Daniel J. George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
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Spees LP, Wheeler SB, Jackson BE, Baggett CD, Wilson LE, Greiner MA, Kaye DR, Zhang T, George D, Scales CD, Pritchard JE, Leapman M, Gross CP, Dinan MA. Provider- and patient-level predictors of oral anticancer agent initiation and adherence in patients with metastatic renal cell carcinoma. Cancer Med 2021; 10:6653-6665. [PMID: 34480518 PMCID: PMC8495289 DOI: 10.1002/cam4.4201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 01/25/2023] Open
Abstract
Background Improving oral anticancer agent (OAA) initiation and adherence is the important quality‐of‐care issues, particularly since one fourth of anticancer agents being developed will be administered orally. Our objective was to identify provider‐ and patient‐level characteristics associated with OAA initiation and adherence among individuals with metastatic renal cell carcinoma (mRCC). Methods We used state cancer registry data linked to multi‐payer claims data to identify patients with mRCC diagnosed in 2004–2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. We estimated risk ratios (RRs) and corresponding 95% confidence limits (CLs) using modified Poisson regression to evaluate factors associated with OAA initiation and adherence. Results Among the 207 (out of 687) patients who initiated an OAA following mRCC diagnosis and survived 90 days, median proportion of days covered was 0.91. Patients with a modal provider specializing in hematology/medical oncology were much more likely to initiate OAAs than those seen by other specialties. Additionally, patients with a female provider were more likely to initiate OAAs than those with a male provider. Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing solely in urban areas were more likely to initiate OAAs, after controlling for patient‐level factors (RR = 1.37; 95% CL: 1.09–1.73). Medicare patients were less likely to be adherent than those with private insurance (RR = 0.61; 95% CL: 0.42–0.87). Conclusions Our results suggest that provider‐ and patient‐level factors influence OAA initiation in patients with mRCC but only insurance type was associated with adherence.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Bradford E Jackson
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center (LCCC), UNC-CH, Chapel Hill, North Carolina, USA.,Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, North Carolina, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Deborah R Kaye
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA
| | - Tian Zhang
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA.,Department of Surgery (Urology), DUSM, Durham, North Carolina, USA
| | - Daniel George
- Duke Cancer Institute (DCI) Center for Prostate and Urologic Cancers, Durham, North Carolina, USA.,Department of Medicine, DUSM, Durham, North Carolina, USA
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA.,Department of Surgery (Urology), DUSM, Durham, North Carolina, USA
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine (DUSM), Durham, North Carolina, USA
| | - Michael Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michaela A Dinan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
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Carnicelli AP, Li Z, Greiner MA, Lippmann SJ, Greene SJ, Mentz RJ, Hardy NC, Blumer V, Shen X, Yancy CW, Peterson PN, Allen LA, Fonarow GC, O'Brien EC. Sacubitril/Valsartan Adherence and Postdischarge Outcomes Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction. JACC Heart Fail 2021; 9:876-886. [PMID: 34509408 DOI: 10.1016/j.jchf.2021.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The authors sought to investigate associations between sacubitril/valsartan adherence and clinical outcomes after hospitalization for heart failure with reduced ejection fraction (HFrEF). BACKGROUND Sacubitril/valsartan improves outcomes in HFrEF, though the extent to which medication adherence is associated with outcomes in routine care is less well characterized. METHODS The authors analyzed patients aged ≥65 years hospitalized for HFrEF within the Get With the Guidelines-Heart Failure registry linked with Medicare claims between October 2015 and September 2018 who were discharged with sacubitril/valsartan. Sacubitril/valsartan adherence was assessed using medication fills to calculate proportion of days covered (PDC) through 90 days postdischarge. Associations between postdischarge adherence (PDC < or ≥80%) and risk of readmission and death within 1 year were examined by comparing cumulative incidences and adjusted event rates. RESULTS Among 897 patients prescribed sacubitril/valsartan at discharge, 295 (32.9%) had PDC ≥80% and 602 (67.1%) had PDC <80%. Baseline characteristics were balanced between groups. Compared with patients with PDC <80%, patients with PDC ≥80% had a significantly lower adjusted hazard of all-cause re-hospitalization (HR: 0.66; [95% CI: 0.48-0.89]) and death (HR: 0.42; [0.22-0.79]) at 90 days and at 1 year (HR: 0.69; [0.56-0.86] and HR: 0.53; [0.38-0.74], respectively). For every 5 percentage point increase in PDC, patients experienced a significant reduction in rehospitalization (HR: 0.98; [0.97-0.99]) and death (HR: 0.96; [0.94-0.97]) at 1 year. CONCLUSIONS In patients hospitalized for HFrEF and discharged on sacubitril/valsartan, high adherence to sacubitril/valsartan within 90 days after discharge was associated with substantially lower rates of readmission and death. Additional efforts to improve adherence with sacubitril/valsartan and other guideline-directed medical therapies in HFrEF are warranted.
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Affiliation(s)
- Anthony P Carnicelli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zhen Li
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vanessa Blumer
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Xian Shen
- Health Economics and Outcomes Research, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Pamela N Peterson
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA; Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.
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Greene SJ, Choi S, Lippmann SJ, Mentz RJ, Greiner MA, Hardy NC, Hammill BG, Luo N, Samsky MD, Heidenreich PA, Laskey WK, Yancy CW, Peterson PN, Curtis LH, Hernandez AF, Fonarow GC, O'Brien EC. Clinical Effectiveness of Sacubitril/Valsartan Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction. J Am Heart Assoc 2021; 10:e021459. [PMID: 34350772 PMCID: PMC8475054 DOI: 10.1161/jaha.121.021459] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Sacubitril/Valsartan has been highly efficacious in randomized trials of heart failure with reduced ejection fraction (HFrEF). However, the effectiveness of sacubitril/valsartan in older patients hospitalized for HFrEF in real‐world US practice is unclear. Methods and Results This study included Medicare beneficiaries age ≥65 years who were hospitalized for HFrEF ≤40% in the Get With The Guidelines–Heart Failure registry between October 2015 and December 2018, and eligible for sacubitril/valsartan. Associations between discharge prescription of sacubitril/valsartan and clinical outcomes were assessed after inverse probability of treatment weighting and adjustment for other HFrEF medications. Overall, 1551 (10.9%) patients were discharged on sacubitril/valsartan. Of those not prescribed sacubitril/valsartan, 7857 (62.0%) were prescribed an angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker. Over 12‐month follow‐up, compared with a discharge prescription of angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker, sacubitril/valsartan was independently associated with lower all‐cause mortality (adjusted hazard ratio [HR], 0.82; 95% CI, 0.72–0.94; P=0.004) but not all‐cause hospitalization (adjusted HR, 0.97; 95% CI, 0.89–1.07; P=0.55) or heart failure hospitalization (adjusted HR, 1.04; 95% CI, 0.91–1.18; P=0.59). Patients prescribed sacubitril/valsartan versus those without a prescription had lower risk of all‐cause mortality (adjusted HR, 0.69; 95% CI, 0.60–0.79; P<0.001), all‐cause hospitalization (adjusted HR, 0.90; 95% CI, 0.82–0.98; P=0.02), but not heart failure hospitalization (adjusted HR, 0.94; 95% CI, 0.82–1.08; P=0.40). Conclusions Among patients hospitalized for HFrEF, prescription of sacubitril/valsartan at discharge was independently associated with reduced postdischarge mortality compared with angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker, and reduced mortality and all‐cause hospitalization compared with no sacubitril/valsartan. These findings support the use of sacubitril/valsartan to improve postdischarge outcomes among older patients hospitalized for HFrEF in routine US clinical practice.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Sujung Choi
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Steven J Lippmann
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Robert J Mentz
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Melissa A Greiner
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - N Chantelle Hardy
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Bradley G Hammill
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Nancy Luo
- Dignity Health Heart and Vascular Institute Sacramento CA
| | - Marc D Samsky
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Paul A Heidenreich
- Department of Medicine Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Warren K Laskey
- Division of Cardiology University of New Mexico School of Medicine Albuquerque NM
| | - Clyde W Yancy
- Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
| | - Pamela N Peterson
- Division of Cardiology University of Colorado, Anschutz Medical Campus Aurora CO.,Division of Cardiology Denver Health Medical Center Denver CO
| | - Lesley H Curtis
- Duke Clinical Research Institute Durham NC.,Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Adrian F Hernandez
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center University of California Los Angeles Los Angeles CA
| | - Emily C O'Brien
- Duke Clinical Research Institute Durham NC.,Department of Population Health Sciences Duke University School of Medicine Durham NC
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Carnicelli AP, Lippmann SJ, Greene SJ, Mentz RJ, Greiner MA, Hardy NC, Hammill BG, Shen X, Yancy CW, Peterson PN, Allen LA, Fonarow GC, O'Brien EC. Sacubitril/Valsartan Initiation and Postdischarge Adherence Among Patients Hospitalized for Heart Failure. J Card Fail 2021; 27:826-836. [PMID: 34364659 DOI: 10.1016/j.cardfail.2021.03.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We investigated associations between timing of sacubitril/valsartan initiation and postdischarge adherence among patients hospitalized for heart failure with reduced ejection fraction (HFrEF). Clinical trials support initiation of sacubitril/valsartan among patients hospitalized with HFrEF. The association between timing of initiation and postdischarge adherence is unknown. METHODS AND RESULTS We analyzed patients hospitalized for HFrEF (EF of ≤40%) within the Get With The Guidelines Heart Failure registry linked with Medicare claims between October 2015 and September 2017 who were eligible for sacubitril/valsartan. Follow-up was through December 2018. Patients were grouped by timing of sacubitril/valsartan initiation. Sacubitril/valsartan adherence at 90 and 365 days after discharge was assessed by calculating proportion of days covered (PDC) using medication fills. Among 4666 patients, 108 (2.3%) were continued on sacubitril/valsartan (on sacubitril/valsartan at admission and discharge), 191 (4.1%) were initiated as inpatients, 130 (2.8%) were initiated at discharge, and 4237 (90.1%) were discharged without sacubitril/valsartan. Median (25th, 75th) proportion of days covered through 90 days among those continued, initiated as inpatients, and initiated at discharge was 0.9 (0.6-0.1), 0.3 (0.0-0.7), and 0.0 (0.0-0.7), respectively (P < .001). Patients discharged without sacubitril/valsartan had very low rates of any sacubitril/valsartan fills within 90 and 365 days of discharge (2.1% and 7.7% of surviving patients, respectively). CONCLUSIONS In 2015-2017 US clinical practice, more than 90% of eligible patients hospitalized for HFrEF were discharged without sacubitril/valsartan. Patients initiated as inpatients had a higher postdischarge proportion of days covered than patients initiated at discharge. Patients discharged without sacubitril/valsartan were unlikely to receive it during follow-up. These findings highlight the importance of initiating sacubitril/valsartan during hospitalization to improve the quality of care.
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Affiliation(s)
- Anthony P Carnicelli
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Bradley G Hammill
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Pamela N Peterson
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Denver, Colorado
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Denver, Colorado
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
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Atwater BD, Li Z, Pritchard J, Greiner MA, Nabutovsky Y, Hammill BG. Early Increased Physical Activity, Cardiac Rehabilitation, and Survival After Implantable Cardioverter-Defibrillator Implantation. Circ Cardiovasc Qual Outcomes 2021; 14:e007580. [PMID: 34284598 DOI: 10.1161/circoutcomes.120.007580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increased physical activity (PA) through cardiac rehabilitation (CR) improves outcomes in patients with heart failure and coronary disease, but CR referral remains infrequent. Implantable cardioverter-defibrillators (ICDs) can provide daily PA measurements to patients that may motivate them to increase PA, but it remains unclear if increased ICD measured PA is associated with improved outcomes with and without CR. METHODS This is a retrospective observational study of 41 731 Medicare beneficiaries with ICD implantation between January 1, 2014 and December 31, 2016. We linked daily ICD PA measurements and Medicare claims data to determine if increased PA is associated with a reduction in the likelihood of death or heart failure hospitalization. To determine if CR participation altered the effect of PA on outcomes, we performed two additional analyses matching CR participants and nonparticipants using propensity scores. The first match included demographics, comorbidities, and baseline PA measurements. The second match also included the change in PA measured during CR or the same time frame after ICD implant among nonparticipants. RESULTS The mean age was 75 (SD, 10) years, 30 182 beneficiaries (72.3%) were male, and 1324 (3%) participated in CR. Increased ICD detected PA was associated with improved survival. CR participants had a mean PA change of +9.7 (SD, 57.8) min/d, whereas nonparticipants had a mean change of -1.0 (SD, 59.7) min/d (P<0.001). After matching for demographics, comorbidities and baseline PA, CR participants had significantly lower 1- to 3-year mortality (hazard ratio, 0.76 [95% CI, 0.69-0.85], P=0.03). After additionally matching for the ICD measured change in PA during CR there were no differences in mortality with and without CR (hazard ratio, 1.00 [95% CI, 0.82-1.21], P=0.87). Every 10 minutes of increased daily PA was associated with a 1.1% reduction in all-cause mortality in both groups. CONCLUSIONS Among Medicare beneficiaries with ICDs, small increases in PA were associated with significant reductions in all-cause mortality.
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Affiliation(s)
- Brett D Atwater
- Inova Heart and Vascular Institute, Fairfax, VA (B.D.A.).,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (B.D.A.)
| | - Zhen Li
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC (Z.L., J.P., M.A.G., B.G.H.)
| | - Jessica Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC (Z.L., J.P., M.A.G., B.G.H.)
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC (Z.L., J.P., M.A.G., B.G.H.)
| | | | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC (Z.L., J.P., M.A.G., B.G.H.)
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Weissler EH, Osazuwa-Peters OL, Greiner MA, Hughes GC, Long CA, Vemulapalli S, Patel MR, Jones WS. National trends in repair for type B aortic dissection. Clin Cardiol 2021; 44:1058-1068. [PMID: 34173677 PMCID: PMC8364733 DOI: 10.1002/clc.23672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Thoracic endovascular aortic repair (TEVAR) first gained in popularity for repair of type B aortic dissections (TBADs) in the early 2000's. We aimed to describe patients undergoing open repair, TEVAR, and no repair and analyze factors associated with repair within 14 days of presentation in the contemporary era. Methods We used the MarketScan database to find patients with TBAD between 2014 and 2017. To assess factors associated with early repair, univariable, and multivariable log‐binomial regression were used. Results There were 2613 patients admitted with TBAD between 2014 and 2017 across the United States, of whom 38.4% underwent repair within 14 days of admission (25.3% open repair and 13.1% TEVAR). The incidence of repair within 14 days decreased over the study period (43% of the study cohort in 2014 to 26.4% in 2017) primarily due to a decrease in open repairs from 30.8% of patients in 2014 to 12.5% in 2017. In multivariable analysis, older age, Middle Atlantic location, diabetes mellitus, insulin use, antiplatelet use, and more recent year were associated with lower likelihood of early repair; male sex, peripheral vascular disease, and the presence of extremity ischemia, rupture, shock, and acidosis were associated with higher likelihood of repair. Conclusions Overall, repair of TBAD within 14 days of presentation declined from 2014 to 2017, with a steady rate of TEVAR but declining rate of open repairs. Further investigation into provider‐ and hospital‐specific factors as they relate to likelihood of repair is needed.
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Affiliation(s)
- E Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oyomoare L Osazuwa-Peters
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - W Schuyler Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
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35
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Wheeler SB, Spees LP, Jackson BE, Baggett CD, Wilson LE, Greiner MA, Kaye DR, Zhang T, George D, Scales CD, Pritchard JE, Dinan MA. Patterns and Predictors of Oral Anticancer Agent Use in Diverse Patients With Metastatic Renal Cell Carcinoma. JCO Oncol Pract 2021; 17:e1895-e1904. [PMID: 34138665 DOI: 10.1200/op.20.01082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Availability of targeted oral anticancer agents (OAAs) has transformed care for patients with metastatic renal cell carcinoma (mRCC). Our objective was to identify patterns and predictors of OAA use within 12 months after mRCC was detected to understand real-world adoption of OAAs. METHODS We used a novel, North Carolina cancer registry-linked multipayer claims data resource to examine patterns of use of five oral therapies among patients with mRCC diagnosed in 2006-2015, with claims through 2016. Patients were required to have 12 months of continuous enrollment before metastatic index date. Log-Poisson models estimated unadjusted and adjusted risk ratios (RRs) for associations between patient characteristics and OAA use. In sensitivity analyses, we used a competing risk framework to estimate adjusted risk differences in OAA use. RESULTS Our population-based study of 713 patients demonstrated low (37%) OAA use during the first year after metastatic index date among both publicly and privately insured patients, with shifting patterns of use consistent with regulatory approvals over time. Compared with patients age 18-49 years, patients age 70-74 years were half likely to use OAAs (95% confidence limit [CL], 0.34 to 0.78) and patients age 80+ years were 71% less likely to use OAAs (95% CL, 0.17 to 0.50). Patients with two comorbidities (RR, 0.73; 95% CL, 0.55 to 0.98) and those with 3+ comorbidities (RR, 0.68; 95% CL, 0.50 to 0.91) were less likely to receive OAA than those without comorbidities. Patients with higher frailty also had lower OAA utilization (RR, 0.67; 95% CL, 0.52 to 0.85). CONCLUSION These findings suggest a need to better understand the system-level and provider-level drivers of OAA underuse, as well as OAA adherence and associated survival.
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Affiliation(s)
- Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC
| | | | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, NC.,Department of Epidemiology, Gillings School of Global Public Health, UNC-CH, Chapel Hill, NC
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Deborah R Kaye
- Department of Medicine, Duke University School of Medicine, Durham, NC.,Department of Surgery (Urology), Duke University School of Medicine, Durham, NC
| | - Tian Zhang
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC.,Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Daniel George
- Department of Surgery (Urology), Duke University School of Medicine, Durham, NC.,Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Charles D Scales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.,Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Michaela A Dinan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.,Duke Cancer Institute, Durham, NC
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Kaufman BG, Van Houtven CH, Greiner MA, Hammill BG, Harker M, Anderson D, Petry S, Bull J, Taylor DH. Selection Bias in Observational Studies of Palliative Care: Lessons Learned. J Pain Symptom Manage 2021; 61:1002-1011.e2. [PMID: 32947017 DOI: 10.1016/j.jpainsymman.2020.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/25/2022]
Abstract
CONTEXT Palliative care (PC) programs are typically evaluated using observational data, raising concerns about selection bias. OBJECTIVES To quantify selection bias because of observed and unobserved characteristics in a PC demonstration program. METHODS Program administrative data and 100% Medicare claims data in two states and a 20% sample in eight states (2013-2017). The sample included 2983 Medicare fee-for-service beneficiaries aged 65+ participating in the PC program and three matched cohorts: regional; two states; and eight states. Confounding because of observed factors was measured by comparing patient baseline characteristics. Confounding because of unobserved factors was measured by comparing days of follow-up and six-month and one-year mortality rates. RESULTS After matching, evidence for observed confounding included differences in observable baseline characteristics, including race, morbidity, and utilization. Evidence for unobserved confounding included significantly longer mean follow-up in the regional, two-state, and eight-state comparison cohorts, with 207 (P < 0.001), 192 (P < 0.001), and 187 (P < 0.001) days, respectively, compared with the 162 days for the PC cohort. The PC cohort had higher six-month and one-year mortality rates of 53.5% and 64.5% compared with 43.5% and 48.0% in the regional comparison, 53.4% and 57.4% in the two-state comparison, and 55.0% and 59.0% in the eight-state comparison. CONCLUSION This case study demonstrates that selection of comparison groups impacts the magnitude of measured and unmeasured confounding, which may change effect estimates. The substantial impact of confounding on effect estimates in this study raises concerns about the evaluation of novel serious illness care models in the absence of randomization. We present key lessons learned for improving future evaluations of PC using observational study designs.
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Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.
| | - Courtney H Van Houtven
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew Harker
- Social Science Research Institute, Duke University, Durham, North Carolina, USA
| | - David Anderson
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Sarah Petry
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | - Donald H Taylor
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA; Sanford School of Public Policy, Duke University, Durham, North Carolina, USA; Social Science Research Institute, Duke University, Durham, North Carolina, USA
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Steinberg BA, Li Z, O'Brien EC, Pritchard J, Chew DS, Bunch TJ, Mark DB, Nabutovsky Y, Greiner MA, Piccini JP. Atrial fibrillation burden and heart failure: Data from 39,710 individuals with cardiac implanted electronic devices. Heart Rhythm 2021; 18:709-716. [PMID: 33508517 PMCID: PMC8096675 DOI: 10.1016/j.hrthm.2021.01.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/11/2021] [Accepted: 01/16/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) and heart failure (HF) often accompany one another, and each is independently associated with poor outcomes. However, the association between AF burden and outcomes is poorly understood. OBJECTIVE The purpose of this study was to describe the association between device-based AF burden and HF clinical outcomes. METHODS We used a nationwide, remote monitoring database of cardiac implantable electronic devices (CIEDs) linked to Medicare claims. We included patients with nonpermanent AF, undergoing new CIED implant, stratified by baseline HF. The outcomes were new-onset HF, HF hospitalization, and all-cause mortality at 1 and 3 years. RESULTS We identified 39,710 patients who met inclusion criteria (25,054 with HF; 14,656 without HF). Patients with HF were younger (mean age 76.3 vs 78.5 years; P <.001), more often male (65% vs 54%; P <.001), and had higher mean CHA2DS2-VASc scores (5.4 vs 4.1; P <.001). Among those without HF, increasing device-based AF burden was significantly associated with increased risk of new-onset HF (adjusted hazard ratio [HR] 1.09 per 10% AF burden; 95% confidence interval [CI] 1.06-1.12; P <.001) and all-cause mortality (adjusted HR 1.05 per 10% AF burden; 95% CI 1.01-1.10; P = .012). Among patients with HF, increasing AF burden was significantly associated with increased risk of HF hospitalization (adjusted HR 1.05 per 10% AF burden; 95% CI 1.04-1.06; P <.001) and all-cause mortality (adjusted HR 1.06 per 10% AF burden; 95% CI 1.05-1.08; P <.001). CONCLUSION Among older patients with AF receiving a CIED, increasing AF burden is significantly associated with increasing risk of adverse HF outcomes and all-cause mortality.
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Affiliation(s)
| | - Zhen Li
- Department of Population Health, Duke University, Durham, North Carolina
| | - Emily C O'Brien
- Department of Population Health, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jessica Pritchard
- Department of Population Health, Duke University, Durham, North Carolina
| | - Derek S Chew
- Department of Population Health, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - T Jared Bunch
- Division of Cardiovascular medicine, University of Utah, Salt Lake City, Utah
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | - Melissa A Greiner
- Department of Population Health, Duke University, Durham, North Carolina
| | - Jonathan P Piccini
- Department of Population Health, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
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Dinan MA, Wilson LE, Greiner MA, Spees L, Pritchard J, Zhang T, Kaye D, George DJ, Scales CD, Wheeler SB. Oral anticancer agent (OAA) adherence and survival in elderly patients with metastatic renal cell carcinoma (mRCC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
280 Background: Multiple effective oral anticancer agents (OAAs) are now approved for the treatment of patients with advanced or metastatic renal cell carcinoma (mRCC) based on improvement in overall and progression-free survival in randomized clinical trials. However, real-world adherence and outcomes associated with OAA use in the general mRCC patient population have not been previously investigated. Methods: Retrospective analysis of SEER-Medicare patients with mRCC who received treatment with an OAA between 2007 and 2015. Adherence was assessed as proportion of days covered (PDC) within 3 months of OAA initiation with PDC > 50% categorized as adherent. The impact of initial OAA adherence on overall and disease-specific survival was analyzed landmarked at 3 months after OAA initiation. Results: A total of 905 patients met study criteria, of which 577 (63.8%) were categorized as adherent to initial OAA treatment. Multivariable analysis adjusting for clinical and demographic factors revealed that living within an impoverished neighborhood was associated with a 20% lower likelihood of adherence (OR 0.80, CI 0.68 – 0.93). No association was observed between adherence and race, ethnicity, marital status, or number of comorbidities. In survival analyses OAA adherence was associated with a significant reduction in both overall (HR 0.71, CI 0.58 – 0.87) and RCC-specific mortality (HR 0.68, CI 0.57 – 0.86). Receipt of sunitinib was associated with a significant reduction in overall and disease specific mortality compared with sorafenib. Post-hoc analysis of patients taking pazopanib as their initial OAA (N = 252) demonstrated reduced all-cause mortality if they received the minimum effective dose of 800 mg daily (HR 0.50, CI 0.35 – 0.72) and decreased adherence associated with initial higher out-of-pocket payments (χ2 test, p = 0.003). Conclusions: Socioeconomic factors predict poor adherence to OAA therapy in Medicare beneficiaries with metastatic RCC, which is in turn associated with poor overall and disease-specific survival. Efforts to improve outcomes and mitigate disparities in the general mRCC population should incorporate considerations of OAA adherence and economic factors. Sunitinib and pazopanib appear associated with favorable survival and remain the most commonly used OAAs in this over 65 year old patient population.
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Affiliation(s)
| | | | | | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Tian Zhang
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
| | - Deborah Kaye
- Dow Division for Urological Health Services Research, Department of Urology, Ann Arbor, MI
| | - Daniel J. George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
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Wheeler SB, Spees L, Jackson BE, Baggett C, Wilson LE, Greiner MA, George DJ, Scales CD, Pritchard J, Dinan MA. Patterns and predictors of oral anticancer agent utilization in diverse metastatic renal cell carcinoma patients. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
279 Background: Availability of targeted oral anti-cancer agents (OAA) has transformed care delivery for metastatic renal cell carcinoma (RCC) patients. Our objective was to identify patterns and predictors of OAA use within the 12 months after metastatic RCC was detected to understand the extent of real-world adoption of these treatment advances. Methods: We used a novel, North Carolina, registry-linked multi-payer claims data resource to examine patterns of use of sorafenib, sunitinib, pazopanib, everolimus, axitinib, cabozantinib, and levantinib in a cohort of metastatic RCC patients diagnosed over 10 years (2006-2015, with claims through 2016). Patients were required to have 12 months of pre- and post-metastatic-index-date continuous enrollment. Log-Poisson models estimated unadjusted and adjusted risk ratios (RRs) and 95% confidence limits (CLs) for associations between patient characteristics and OAA use. In sensitivity analyses, we used a competing risk framework to estimate adjusted risk differences (RD) in OAA use. Results: Our population-based study of 713 patients demonstrated relatively low (37%) OAA use at any time during the 12 months post-metastatic-index date among publicly and privately insured patients, with shifting patterns of use consistent with regulatory approvals over time. Lower OAA use was observed among patients who were older, frailer, and with greater comorbidity burden. Other patient-level characteristics, such as sex, race, rurality and type of insurance were not significant predictors of OAA use. Conclusions: These data underscore the importance of distinguishing clinically appropriate from potentially poor-quality care and warrant additional studies to understand in more depth the system, provider and patient level drivers of these patterns.
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Affiliation(s)
| | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | - Daniel J. George
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC
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Samsky MD, Lin L, Greene SJ, Lippmann SJ, Peterson PN, Heidenreich PA, Laskey WK, Yancy CW, Greiner MA, Hardy NC, Kavati A, Park S, Mentz RJ, Fonarow GC, O'Brien EC. Patient Perceptions and Familiarity With Medical Therapy for Heart Failure. JAMA Cardiol 2021; 5:292-299. [PMID: 31734700 DOI: 10.1001/jamacardio.2019.4987] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance There are major gaps in use of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). Patient-reported data outlining patient goals and preferences associated with GDMT are not available. Objective To survey patients with chronic HF to better understand their experiences and perceptions of living with HF, including their familiarity and concerns with important GDMT therapies. Design, Setting, and Participants Study participants were recruited from the GfK KnowledgePanel, a probability-sampled online panel representative of the US adult population. English-speaking adults who met the following criteria were eligible if they were (1) previously told by a physician that they had HF; (2) currently taking medications for HF; and (3) had no history of left ventricular assist device or cardiac transplant. Data were collected between October and November 2018. Analysis began in December 2018. Main Outcomes and Measures The survey included 4 primary domains: (1) relative importance of disease-related goals, (2) challenges associated with living with HF, (3) decision-making process associated with HF medication use, and (4) awareness and concerns about available HF medications. Results Of 30 707 KnowledgePanel members who received the initial survey, 15 091 (49.1%) completed the screening questions, 440 were eligible and began the survey, and 429 completed the survey. The median (interquartile range) age was 68 (60-75) years and most were white (320 [74.6%]), male (304 [70.9%]), and had at least a high school education (409 [95.3%]). Most survey responders reported familiarity with β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. Overall, 107 (24.9%) reported familiarity with angiotensin receptor-neprilysin inhibitors or mineralocorticoid receptor antagonists. Overall, 136 patients (42.5%) reported have safety concerns regarding angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 133 (38.5%) regarding β-blockers, 35 (37.9%) regarding mineralocorticoid receptor antagonists, 38 (36.5%) regarding angiotensin receptor-neprilysin inhibitors, and 123 (37.2%) regarding diuretics. Between 27.7% (n = 26) and 38.5% (n = 136) reported concerns regarding the effectiveness of β-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists, or diuretics, while 41% (n = 132) were concerned with the effectiveness of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. Conclusions and Relevance In this survey study, many patients were not familiar with GDMT for HF, with familiarity lowest for angiotensin receptor-neprilysin inhibitors and mineralocorticoid receptor antagonists. Among patients not familiar with these therapies, significant proportions questioned their effectiveness and/or safety. Enhanced patient education and shared decision-making support may be effective strategies to improve the uptake of GDMT for HF in US clinical practice.
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Affiliation(s)
- Marc D Samsky
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Li Lin
- Duke Clinical Research Institute, Durham, North Carolina
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical Campus, Aurora.,Division of Cardiology, Denver Health Medical Center, Denver, Colorado
| | - Paul A Heidenreich
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Warren K Laskey
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Deputy Editor
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Abhishek Kavati
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Siyeon Park
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, Baltimore
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles, Cardiomyopathy Center, University of California, Los Angeles.,Section Editor
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Wilson LE, Greiner MA, Altomare I, Rotter J, Dinan MA. Rapid rise in the cost of targeted cancer therapies for Medicare patients with solid tumors from 2006 to 2015. J Geriatr Oncol 2020; 12:375-380. [PMID: 33250425 DOI: 10.1016/j.jgo.2020.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/24/2020] [Accepted: 11/20/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Inflation-adjusted cancer costs in the United States have increased 40% in the last decade, leading to increasing financial burden on both payers and patients. Patients under 65 show substantial increases in utilization of expensive targeted therapy anticancer agents; however, patients aged 65+ account for the majority of new malignancies. Utilization and cost trends for these emerging agents have not been examined in detail in the Medicare population. PATIENTS AND METHODS Retrospective prevalent cohort analysis of patients 65+ with any stage of invasive lung, breast, colorectal, or prostate cancer, receiving systemic therapy drawn from the United States Medicare 5% fee-for-service sample claims (2005-2015). Yearly trends in utilization and associated costs were modeled with adjustment for inflation, demographics, and comorbidities. RESULTS Among Medicare beneficiaries with fee-for-service and Part D enrollment who were receiving some type of systemic anticancer therapy, there were 9230 patients with colorectal, 32,738 patients with breast, and 16,278 patients with lung cancers identified from 2006 to 2015, and 19,295 patients with prostate cancer from 2009 to 2015. The share of cancer costs to Medicare attributable to targeted therapies, increased dramatically for prostate cancer (1.7% to 19.4%), lung cancer (6.7% to 19.4%), colorectal cancer (11.7% to 22.2%), and breast cancer (15.8% to 25.5%). Although the proportion of patients receiving targeted therapies remained stable, mean per-patient cancer costs increased dramatically from 2006 to 2015 for patients with lung or prostate cancer receiving targeted therapy and for patients with breast cancer receiving non-hormonal targeted therapies. Targeted agents for these cancers showed substantial inflation-adjusted price growth over this time period.
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Affiliation(s)
- Lauren E Wilson
- Department of Population Health Science, Duke University School of Medicine, Durham, USA.
| | - Melissa A Greiner
- Department of Population Health Science, Duke University School of Medicine, Durham, USA
| | - Ivy Altomare
- Division of Medical Oncology, Duke University School of Medicine, Durham, USA
| | - Jason Rotter
- Department of Population Health Science, Duke University School of Medicine, Durham, USA
| | - Michaela A Dinan
- Department of Population Health Science, Duke University School of Medicine, Durham, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, USA
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Wilson LE, Spees L, Pritchard J, Greiner MA, Scales CD, Baggett C, Kaye D, George DJ, Zhang T, Wheeler SB, Dinan MA. Disparities in utilization of oral anticancer agents and related costs in elderly patients with metastatic renal cell carcinoma in the United States. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
106 Background: Although survival among patients with metastatic renal cell carcinoma (mRCC) has improved with the introduction of targeted therapies, substantial disparities in mRCC survival persist. The purpose of this study was to identify patient characteristics associated with differential adoption of emerging oral anticancer agents (OAAs) and related costs in the management of mRCC. Methods: SEER-Medicare patients diagnosed with mRCC aged 65 years or older from 2007-2015 continuously enrolled in Medicare Part D benefits for at least 1 year after diagnosis or until death were included. Associations between patient-level characteristics and OAA receipt were analyzed using univariable and multivariable log-binomal regression; associations between patient characteristics, OAA receipt, and total, cancer-specific, and OAA-specific costs in the 12 months following diagnosis were modeled as relative cost ratios using generalized linear regression with a gamma link. Reported costs were adjusted to 2015 dollars. Results: 2,792 patients with mRCC met inclusion criteria; 32.4% received an OAA in the 12 months following diagnosis. The majority of patients receiving an OAA used either sunitinib or pazopanib. Receipt increased slightly over the study period from 2007 (31% of patients) to 2015 (37%). In multivariable-adjusted models, patients of advanced age ( > 80 years RR 0.50; 95% CI 0.42-0.60) or residing in the Southern US (RR 0.83 95% CI 0.70-0.98) were less likely to receive OAAs. Married patients were 20% more likely (RR 1.19; 95% CI 1.04-1.37) to receive OAAs. After multivariable adjustment, receipt of OAAs was associated with higher total and cancer-specific costs, as was Hispanic ethnicity. Among patients receiving an OAA, the cost of OAAs to Medicare increased approximately 7% per year (95% CI 4%-9%), while patient out-of-pocket spending for OAAs decreased approximately 10% per year (95% CI 7%-14%). Out-of-pocket OAA costs were consistently lower for Black, Hispanic, and Other patient race/ethnicity categories compared to the White Non-Hispanic category. Conclusions: Patient characteristics including age at metastatic diagnosis, marital status, geographic region, and certain comorbidities are related to the likelihood of receiving OAAs. Future research is warranted to investigate if such differences in OAA use lead to differences in survival.
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Affiliation(s)
| | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Chris Baggett
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deborah Kaye
- Dow Division for Urological Health Services Research, Department of Urology, Ann Arbor, MI
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Weissler EH, Lippmann SJ, Smerek MM, Ward RA, Kansal A, Brock A, Sullivan RC, Long C, Patel MR, Greiner MA, Hardy NC, Curtis LH, Jones WS. Model-Based Algorithms for Detecting Peripheral Artery Disease Using Administrative Data From an Electronic Health Record Data System: Algorithm Development Study. JMIR Med Inform 2020; 8:e18542. [PMID: 32663152 PMCID: PMC7468640 DOI: 10.2196/18542] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/21/2020] [Accepted: 06/28/2020] [Indexed: 12/18/2022] Open
Abstract
Background Peripheral artery disease (PAD) affects 8 to 10 million Americans, who face significantly elevated risks of both mortality and major limb events such as amputation. Unfortunately, PAD is relatively underdiagnosed, undertreated, and underresearched, leading to wide variations in treatment patterns and outcomes. Efforts to improve PAD care and outcomes have been hampered by persistent difficulties identifying patients with PAD for clinical and investigatory purposes. Objective The aim of this study is to develop and validate a model-based algorithm to detect patients with peripheral artery disease (PAD) using data from an electronic health record (EHR) system. Methods An initial query of the EHR in a large health system identified all patients with PAD-related diagnosis codes for any encounter during the study period. Clinical adjudication of PAD diagnosis was performed by chart review on a random subgroup. A binary logistic regression to predict PAD was built and validated using a least absolute shrinkage and selection operator (LASSO) approach in the adjudicated patients. The algorithm was then applied to the nonsampled records to further evaluate its performance. Results The initial EHR data query using 406 diagnostic codes yielded 15,406 patients. Overall, 2500 patients were randomly selected for ground truth PAD status adjudication. In the end, 108 code flags remained after removing rarely- and never-used codes. We entered these code flags plus administrative encounter, imaging, procedure, and specialist flags into a LASSO model. The area under the curve for this model was 0.862. Conclusions The algorithm we constructed has two main advantages over other approaches to the identification of patients with PAD. First, it was derived from a broad population of patients with many different PAD manifestations and treatment pathways across a large health system. Second, our model does not rely on clinical notes and can be applied in situations in which only administrative billing data (eg, large administrative data sets) are available. A combination of diagnosis codes and administrative flags can accurately identify patients with PAD in large cohorts.
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Affiliation(s)
- Elizabeth Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Michelle M Smerek
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Rachael A Ward
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Aman Kansal
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Adam Brock
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Robert C Sullivan
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Manesh R Patel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.,Department of Medicine, Duke University School of Medicine, Durham, NC, United States.,Duke Clinical Research Institute, Durham, NC, United States
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Lesley H Curtis
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.,Duke Clinical Research Institute, Durham, NC, United States
| | - W Schuyler Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.,Department of Medicine, Duke University School of Medicine, Durham, NC, United States.,Duke Clinical Research Institute, Durham, NC, United States
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Brander DM, Oeffinger KC, Greiner MA, Dinan MA. Prevalence, screening, treatment, and complications of osteoporosis and osteopenia in Medicare patients with chronic lymphocytic leukemia (CLL). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e24050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24050 Background: Despite treatment advances, patients (pts) with CLL, a common chronic cancer affecting the elderly, often experience adverse outcomes due to their comorbidities and frequent lack of routine health maintenance. We examined osteoporosis/osteopenia (OSTEO) prevalence, rates of bone mineral density (BMD, g/cm2) screening by dual-energy x-ray absorptiometry (DXA), use of bisphosphonates, and fragility fractures among Medicare pts with CLL. Methods: We identified a cohort of CLL pts >65 years with Medicare fee-for-service between 1/1/2011-12/31/2015 using the Medicare 5% national sample. Controls (5:1) were matched based on age, sex, race, and year of eligibility. Among those with OSTEO, we compared rates of bisphosphonates. Chi-square tests for categorical variables and Wilcoxon Rank-sum tests for continuous variables were used to compare CLL vs controls. Cumulative incidence of BMD screening and fragility fractures were estimated using the cumulative incidence function and compared to controls using Gray tests. For fragility fractures, we compared among subgroups with and without OSTEO. Results: Baseline characteristics are in the Table. Compared to controls, CLL pts were more likely to have OSTEO (p < .001) but less bisphosphonate use (p = .006). The 3-yr cumulative incidence of fragility fractures was higher among CLL pts (8.0%, 95% CI 7.5%-8.6%) vs controls (7.2%, 6.9%-7.4%; p = .002) as well as among those without an OSTEO diagnosis (p = .02). Cumulative 3-yr DXA use was higher among CLL pts vs controls ( < .001); however, DXA 3-yr incidence was lower in CLL pts who had chemotherapy (13.2%, 11.4%-15.4%) vs none (17.0%, 16.2%-17.9%, p = .002). Conclusions: It appears that CLL pts may have a higher risk of osteoporosis and higher rates of fragility fractures than non-CLL individuals. Fragility fractures are higher even in the subgroup of CLL pts without OSTEO, suggesting that pts may be underdiagnosed. [Table: see text]
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Luo N, Lippmann SJ, Mentz RJ, Greiner MA, Hammill BG, Hardy NC, Laskey WK, Heidenreich PA, Chang CL, Hernandez AF, Curtis LH, Peterson PN, Fonarow GC, O'Brien EC. Relationship Between Hospital Characteristics and Early Adoption of Angiotensin-Receptor/Neprilysin Inhibitor Among Eligible Patients Hospitalized for Heart Failure. J Am Heart Assoc 2020; 8:e010484. [PMID: 30712431 PMCID: PMC6405590 DOI: 10.1161/jaha.118.010484] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background The angiotensin‐receptor/neprilysin inhibitor (ARNI) sacubitril/valsartan reduces hospitalization and mortality for patients with heart failure with reduced ejection fraction. However, adoption of ARNI into clinical practice has been slow. Factors influencing use of ARNI have not been fully elucidated. Using data from the Get With The Guidelines‐Heart Failure registry, Hospital Compare, Dartmouth Atlas, and the American Hospital Association Survey, we sought to identify hospital characteristics associated with patient‐level receipt of an ARNI prescription. Methods and Results We analyzed patients with heart failure with reduced ejection fraction who were eligible for ARNI prescription (ejection fraction≤40%, no contraindications) and hospitalized from October 1, 2015 through December 31, 2016. We used logistic regression to estimate the associations between hospital characteristics and patient ARNI prescription at hospital discharge, accounting for clustering of patients within hospitals using generalized estimating equation methods and adjusting for patient‐level covariates. Of 16 674 eligible hospitalizations from 210 hospitals, 1020 patients (6.1%) were prescribed ARNI at discharge. The median hospital‐level proportion of patients prescribed ARNI was 3.3% (Q1, Q3: 0%, 12.6%). After adjustment for patient‐level covariates, for‐profit hospitals had significantly higher odds of ARNI prescription compared with not‐for‐profit hospitals (odds ratio, 2.53; 95% CI, 1.05–6.10; P=0.04), and hospitals located in the Western United States had lower odds of ARNI prescription compared with those in the Northeast (odds ratio, 0.33; 95% CI, 0.13–0.84; P=0.02). Conclusions Relatively few hospital characteristics were associated with ARNI prescription at hospital discharge, in contrast to what has been observed in early adoption in other disease areas. Additional evaluation of barriers to implementing new evidence into heart failure practice is needed. See Editorial by Bergethon and Wasfy
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Affiliation(s)
- Nancy Luo
- 1 Division of Cardiovascular Medicine University of California-Davis Medical Center Sacramento CA
| | - Steven J Lippmann
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Robert J Mentz
- 3 Department of Medicine Duke University School of Medicine Durham NC.,4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Melissa A Greiner
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Bradley G Hammill
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - N Chantelle Hardy
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Warren K Laskey
- 5 Division of Cardiology University of New Mexico School of Medicine Albuquerque NM
| | - Paul A Heidenreich
- 6 Department of Medicine Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Chun-Lan Chang
- 7 US Health Economics & Outcomes Research Novartis Pharmaceuticals Corporation East Hanover NJ
| | - Adrian F Hernandez
- 3 Department of Medicine Duke University School of Medicine Durham NC.,4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Lesley H Curtis
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC.,4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Pamela N Peterson
- 8 Department of Medicine Denver Health Medical Center Denver CO.,9 Anschutz Medical Center University of Colorado Aurora CO
| | - Gregg C Fonarow
- 10 Ahmanson-UCLA Cardiomyopathy Center University of California Los Angeles CA
| | - Emily C O'Brien
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC.,4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
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Kelly JP, Ballew NG, Lin L, Hammill BG, Stivland TM, Jones PW, Curtis LH, Hernandez AF, Greiner MA, Atwater BD. Association of Implantable Device Measured Physical Activity With Hospitalization for Heart Failure. JACC Heart Fail 2020; 8:280-288. [PMID: 32035894 DOI: 10.1016/j.jchf.2019.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 10/08/2019] [Accepted: 10/31/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the association of physical activity (PA) level and longitudinal PA trajectory with a composite heart failure hospitalization and mortality endpoint over a 5-year follow-up period following implantation. BACKGROUND Low device measured PA early after implantation of an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) is associated with poor outcomes. METHODS We linked daily PA data from the Boston Scientific ALTITUDE dataset of patients with ICD or CRT-D implantation to Medicare claims data. We used a joint model to investigate the association of the composite endpoint with 1) the time-varying point estimate of PA and 2) the time-varying trajectory/slope of PA during follow-up. RESULTS Among 20,927 patients with median activity level 85 min/day, 14.1% and 49.6% experienced the composite endpoint at 1 and 5 years. Adjusted joint model results showed that there was a 1.13 (95% confidence interval: 1.12 to 1.13)-fold increase in the hazard of the composite endpoint for 75 min of daily PA relative to 85 min of PA; and a within-patient 10-min decrease in average daily PA over an 8-week period from 85 to 75 min was associated with a hazard ratio of 4.02 (95% confidence interval: 3.82 to 4.22) for the composite endpoint. CONCLUSIONS Patients with large decreases in PA have significantly higher risk of experiencing heart failure hospitalization or death. PA data from implantable devices may identify patients before clinical decompensation.
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Affiliation(s)
- Jacob P Kelly
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina; Alaska Heart & Vascular Institute, Anchorage, Alaska.
| | - Nicholas G Ballew
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Li Lin
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Bradley G Hammill
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Paul W Jones
- Boston Scientific Corporation, St. Paul, Minnesota
| | - Lesley H Curtis
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Adrian F Hernandez
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Brett D Atwater
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
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Long CA, Zepel L, Greiner MA, Hammill BG, Patel MR, Jones WS. Use and 1-year outcomes with conventional and drug-coated balloon angioplasty in patients with lower extremity peripheral artery disease. Am Heart J 2019; 217:42-51. [PMID: 31473326 DOI: 10.1016/j.ahj.2019.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/19/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND With the growing use of drug-coated balloons for the treatment of peripheral artery disease, information regarding the safety and effectiveness of drug-coated balloons in current practice is needed. We examined patient, physician, and procedural characteristics as well as cardiovascular and limb events in patients who underwent peripheral vascular intervention with drug-coated balloons. METHODS This is a retrospective cohort analysis utilizing Medicare data for 100% of fee-for-service beneficiaries from 2015 to 2016 who had a claim for femoropopliteal intervention. The use of drug-coated balloons was identified via specific transitional pass-through codes. All-cause mortality, all-cause hospitalization, repeat femoropopliteal intervention, and major lower extremity amputation at 1 year were the clinical outcomes of interest. RESULTS In total, 83,225 patients underwent femoropopliteal intervention, and drug-coated balloons were utilized in 29% of all procedures. Patients treated with drug-coated balloons had a lower cumulative incidence of all-cause hospitalization, all-cause mortality, and major lower extremity amputation, but were more likely to undergo repeat femoropopliteal intervention when compared with patients treated with conventional balloon angioplasty. After adjustment for measured confounders, patients treated with drug-coated balloons had lower rates of hospitalization (HR 0.91 (0.88, 0.93), P < .001), all-cause mortality (HR 0.89 [0.84, 0.94], P < .001), and major amputation (HR 0.93 [0.88, 0.99], P = .017). CONCLUSIONS Patients who underwent femoropopliteal intervention with drug-coated balloons had lower observed rates of all-cause mortality, all-cause hospitalization, and major amputation at 1 year. Interestingly, there was not a reduction in rates of repeat revascularization, and further work is required to understand this finding. Nevertheless, the use of drug-coated balloons appears to be safe in this large study of contemporary patients in the United States.
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Greene SJ, Lippmann SJ, Mentz RJ, Greiner MA, Hardy NC, Chang CL, Hammill BG, Luo N, Samsky MD, Heidenreich PA, Laskey WK, Yancy CW, Peterson PN, Curtis LH, Hernandez AF, Fonarow GC, O'Brien EC. Clinical Effectiveness of Sacubitril/valsartan among Patients Hospitalized for Heart Failure with Reduced Ejection Fraction. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Steinberg BA, Ballew NG, Greiner MA, Lippmann SJ, Curtis LH, O'Brien EC, Patel MR, Piccini JP. Ischemic and Bleeding Outcomes in Patients With Atrial Fibrillation and Contraindications to Oral Anticoagulation. JACC Clin Electrophysiol 2019; 5:1384-1392. [PMID: 31857036 DOI: 10.1016/j.jacep.2019.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/21/2019] [Accepted: 07/11/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study sought to describe clinical outcomes among patients with atrial fibrillation (AF) and contraindications to oral anticoagulation (OAC). BACKGROUND Treatment with OAC prevents stroke and death in patients with AF, but may be contraindicated among patients at high bleeding risk. METHODS This was an observational, longitudinal analysis of a nationally representative 5% Medicare sample of patients with chronic AF and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score ≥2. They were stratified by both the presence of high bleeding risk contraindications to OAC and by OAC use. We assessed 3-year ischemic and bleeding outcomes using multivariable Cox proportional hazards models adjusted for relevant patient characteristics. RESULTS Among 26,684 AF patients not treated with OAC, 8,283 (31%) had a high bleeding risk contraindication, primarily a blood dyscrasia (75%) or history of gastrointestinal bleeding (40%). Without OAC, patients with contraindications had worse ischemic and bleeding outcomes at 3 years compared with those without contraindications. We also identified 12,454 patients with OAC contraindications who received OAC. Compared with patients not receiving OAC, use of OAC was associated with reduced mortality (adjusted hazard ratio [HR]: 0.79; 95% confidence interval [CI]: 0.76 to 0.83), stroke (adjusted HR: 0.90; 95% CI: 0.83 to 0.99), and all-cause hospitalization (adjusted HR: 0.93; 95% CI: 0.90 to 0.96) but increased risk of intracranial hemorrhage (adjusted HR: 1.42; 95% CI: 1.17 to 1.72). CONCLUSIONS High bleeding risk contraindications to OAC are common among older patients with AF, and these patients have higher mortality compared with untreated patients without OAC contraindications. The use of OAC in these patients is associated with lower rates of all-cause stroke, hospitalization, and death but higher risk of intracranial hemorrhage.
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Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah.
| | - Nicholas G Ballew
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Lesley H Curtis
- Department of Population Health Sciences, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Manesh R Patel
- Duke Clinical Research Institute, Durham, North Carolina; Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Department of Population Health Sciences, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Cardiology Division, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Foraker RE, Bush C, Greiner MA, Sims M, Henderson K, Smith S, Bidulescu A, Shoben AB, Hardy NC, O'Brien E. Distribution of Cardiovascular Health by Individual- and Neighborhood-Level Socioeconomic Status: Findings From the Jackson Heart Study. Glob Heart 2019; 14:241-250. [PMID: 31196828 DOI: 10.1016/j.gheart.2019.04.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/30/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Data demonstrate a positive relationship between socioeconomic status (SES) and cardiovascular health (CVH). OBJECTIVE To assess the association between individual- and neighborhood-level SES and CVH among participants of the JHS (Jackson Heart Study), a community-based cohort of African Americans in Jackson, Mississippi. METHODS We included all JHS participants with complete SES and CVH information at the baseline study visit (n = 3,667). We characterized individual- and neighborhood-level SES according to income (primary analysis) and education (secondary analysis), respectively. The outcome of interest for these analyses was a CVH score, based on 7 modifiable behaviors and factors, summed to a total of 0 (worst) to 14 (best) points. We utilized generalized estimating equations to account for the clustering of participants within the same residential areas to estimate the linear association between SES and CVH. RESULTS The median age of the participants was 55 years, and 64% were women. Nearly one-third of eligible participants had individual incomes <$20,000 and close to 40% lived in the lowest neighborhood income category (<$25,480). Adjusted for age, sex, and neighborhood SES, there was an average increase in CVH score of 0.31 points associated with each 1-category increase in individual income. Similarly, each 1-category increase in neighborhood SES was associated with a 0.19-point increase in CVH score. These patterns held for our secondary analyses, which used educational attainment in place of income. These data did not suggest a synergistic effect of individual- and neighborhood-level SES on CVH. CONCLUSIONS Our findings suggest a potential causal pathway for disparities in CVH among vulnerable populations. These data can be useful to the JHS community to empower public health and clinical interventions and policies for the improvement of CVH.
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Affiliation(s)
- Randi E Foraker
- Institute for Informatics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | | | | | - Mario Sims
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Kamal Henderson
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sakima Smith
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Abigail B Shoben
- The Ohio State University College of Public Health, Columbus, OH, USA
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